Ecstasy (MDMA, MDA, MDEA, MBDB) consumption, seizures, related offences, prices, dosage levels and deaths in the UK (1994-2003)

First Death Involving 4-Fluoroethylphenidate (4F-EPH): Case Report, User Experiences, and Review of the Related Literature

Background

4-Fluoroethylphenidate (4F-EPH) is a psychoactive substance, sold primarily over the Internet as a `research chemical'. Recreational and `functional' use of this drug has been reported by online user fora. Scientifically-based data on the pharmacological, physiological, psychopharmacological, toxicological, and epidemiological characteristics of this molecule is non-existent. The aim of this paper is to remedy this situation.

Methods

Recent literature (including 'grey') was searched to update what is known about 4F-EPH, especially its toxicity. This was supplemented by netnographic examinations of internet sites.

Results

The resultant information is presented, including details of the first reported death involving 4F-EPH use in 2016. There are no international controls imposed on 4F-EPH. However, it has been made a controlled drug in several European countries, including the United Kingdom since 31 May 2017, as well as Canada.

Conclusions

It is vital that any other cases, including non-fatal overdoses, are documented so that a firmer scientific evidence-base can be established for this molecule. This will then help inform clinical practice.

Detection of 3,4-Methylene Dioxy Amphetamine in Urine by Magnetically Improved Surface-Enhanced Raman Scattering Sensing Strategy

Abuse of illicit drugs has become a major issue of global concern. As a synthetic amphetamine analog, 3,4-Methylene Dioxy Amphetamine (MDA) causes serotonergic neurotoxicity, posing a serious risk to human health. In this work, a two-dimensional substrate of ITO/Au is fabricated by transferring Au nanoparticle film onto indium–tin oxide glass (ITO). By magnetic inducing assembly of Fe₃O₄@Au onto ITO/Au, a sandwich-based, surface-enhanced Raman scattering (SERS) detection strategy is designed. Through the use of an external magnet, the MDA is retained in the region of hot spots formed between Fe₃O₄@Au and ITO/Au; as a result, the SERS sensitivity for MDA is superior compared to other methods, lowering the limit of detection (LOD) to 0.0685 ng/mL and attaining a corresponding linear dynamic detection range of 5–10⁵ ng/mL. As an actual application, this magnetically improved SERS sensing strategy is successfully applied to distinguish MDA in urine at trace level, which is beneficial to clinical and forensic monitors.

Recreational ketamine-related deaths notified to the National Programme on Substance Abuse Deaths, England, 1997-2019

BACKGROUND

Ketamine is a phencyclidine derivative with dissociative anaesthetic properties. Increasing numbers of individuals in England take ketamine recreationally. Information on deaths arising from such use in England is presented.

METHODS

Cases were extracted on 31 January 2020 from the National Programme on Substance Abuse Deaths database, based on text searches of the cause of death, coroner's verdict and positive toxicology results for the terms 'ketamine' or 'norketamine'.

FINDINGS

During 1997-2005, there were <5 deaths p.a. in which ketamine was implicated. Numbers increased until 2009 (21), plateauing until 2016; thereafter, deaths have risen to about 30 p.a. Decedents' characteristics (N = 283): male 84.1%, mean age 31.2 (SD 10.0) years, employed 56.5%, drug use history 79.6% and living with others 60.3%. Ketamine was detected with other substances in most cases. Main (74.6%) underlying cause of death was accidental poisoning. Ketamine may have impaired judgement in other cases.

CONCLUSIONS

Although controlled, recreational ketamine use and related fatalities continue to increase. Consumers need to be more aware of the potentially fatal risks they face.

A revised excretion factor for estimating ketamine consumption by wastewater-based epidemiology - Utilising wastewater and seizure data

The rate of drug excretion (excretion factor) is a critical parameter for monitoring drug consumption in the population by wastewater-based epidemiology (WBE). Previous studies have refined excretion factors for common illicit drugs, such as cocaine, amphetamine, methamphetamine, heroin, to improve the accuracy and reduce uncertainty in back-calculating consumption. Nevertheless, for ketamine, one of the most prevalent psychoactive substances, a careful review of its excretion factors has not been performed due to limited pharmacokinetic data. Here we review WBE studies and seizure data to refine and validate the excretion factors for ketamine and norketamine. The average ketamine/norketamine ratio in wastewater (5.36) was much higher than that found in urine (0.64), which means that the excretion factors derived only from pharmacokinetics data are not appropriate. Based on the comparison of the ratio between estimated consumptions of ketamine and methamphetamine by WBE with their corresponding ratio in official seizure data, a revised WBE excretion factor of 20% was proposed for ketamine following this review and applied to estimate the ketamine consumption in China. The revised estimates of ketamine consumption corresponded well with drug statistics. This suggests that the revised ketamine excretion factor is appropriate for estimating ketamine consumption by WBE. Systematic review of WBE studies is a suitable approach to refine the excretion factors for substances with inadequate pharmacokinetic data.

Recreational use of psychedelics is associated with elevated personality trait openness: Exploration of associations with brain serotonin markers

BACKGROUND

Recent studies have suggested therapeutic benefits of psychedelics for a variety of mental health conditions. The understanding of how single psychedelic administrations can induce long-lasting effects are, in large, still lacking. However, recent studies in both healthy and clinical populations suggest a role for personality changes.

AIM

To test support for some of these plausible mechanisms we evaluated (cross-sectional) associations between recreational use of psychedelics and 3,4-methylene-dioxymethamphetamine (MDMA) and (a) personality measures and (b) key markers of cerebral serotonergic signalling (serotonin transporter and serotonin-2A-receptor binding).

METHODS

In 10 psychedelic-preferring recreational users, 14 MDMA-preferring users and 21 non-using controls, personality was assessed using the 'big five' instrument Revised NEO Personality Inventory (NEO-PI-R). Frontal serotonin transporter and serotonin-2A-receptor binding potentials were quantified using [¹¹C]DASB and [¹⁸F]altanserin positron emission tomography, respectively.

RESULTS

Of the five NEO-PI-R traits, only openness to experience scores differed between the three groups; psychedelic-preferring recreational users showing higher openness to experience scores when compared with both MDMA-preferring users and controls. Openness to experience scores were positively associated with lifetime number of psychedelic exposures, and among all MDMA-preferring user/psychedelic-preferring recreational user individuals, frontal serotonin transporter binding - but not frontal serotonin-2A-receptor binding - was positively associated with openness to experience.

CONCLUSION

Our findings from this cross-sectional study support increasing evidence of a positive association between psychedelic experiences and openness to experience, and (a) expands this to the context of 'recreational' psychedelics use, and (b) links serotonergic neurotransmission to openness to experience. A modulation of personality induced by psychedelic experiences may have important therapeutic implications via its impact on peoples' value systems, cognitive flexibility, and individual and social behaviour.

Characteristics of deaths associated with kratom use

BACKGROUND

Kratom (Mitragyna speciosa Korth) use has increased in Western countries, with a rising number of associated deaths. There is growing debate about the involvement of kratom in these events.

AIMS

This study details the characteristics of such fatalities and provides a 'state-of-the-art' review.

METHODS

UK cases were identified from mortality registers by searching with the terms 'kratom', 'mitragynine', etc. Databases and online media were searched using these terms and 'death', 'fatal*', 'overdose', 'poisoning', etc. to identify additional cases; details were obtained from relevant officials. Case characteristics were extracted into an Excel spreadsheet, and analysed employing descriptive statistics and thematic analysis.

RESULTS

Typical case characteristics (n = 156): male (80%), mean age 32.3 years, White (100%), drug abuse history (95%); reasons for use included self-medication, recreation, relaxation, bodybuilding, and avoiding positive drug tests. Mitragynine alone was identified/implicated in 23% of cases. Poly substance use was common (87%), typically controlled/recreational drugs, therapeutic drugs, and alcohol. Death cause(s) included toxic effects of kratom ± other substances; underlying health issues.

CONCLUSIONS

These findings add substantially to the knowledge base on kratom-associated deaths; these need systematic, accurate recording. Kratom's safety profile remains only partially understood; toxic and fatal levels require quantification.

Nonmedical prescription drug use among African Americans who use MDMA (ecstasy/molly): Implications for risk reduction

Recent data suggest that both nonmedical prescription drug and MDMA (ecstasy/molly) use have risen among African Americans. However, studies investigating these two forms of drug use among African Americans are rare. As a result, very little is known about African-American MDMA users and their nonmedical use of prescription medications. The primary goal of this study, therefore, was to describe patterns of nonmedical prescription drug use among African Americans who use MDMA. We also assessed alcohol and illicit drug use among the sample. Surveys (n=100) and in-depth interviews (n=15) were conducted with African-American young adults in Southwest Florida between August 2014 and November 2015. Survey results show that a significant proportion of the sample used MDMA in conjunction with prescription medications (benzodiazepines=59%; opioids=35%; stimulants=13%). Qualitative findings suggest that benzodiazepine medications were used to alleviate MDMA comedown symptoms, opioids were used to achieve a different quality high, and stimulants were used to provide added energy throughout the night. These results suggest that treatment practitioners and harm reduction professionals should pay particular attention to informing users of the potential hazards of combining MDMA with prescription medications. Although additional research is clearly needed, these findings are an important first step towards understanding both nonmedical prescription drug and MDMA use among African Americans, and could be used to tailor treatment and risk reduction interventions to this population.

The potential utility of some legal highs in CNS disorders

Over the last decade there has been an explosion of new drugs of abuse, so called legal highs or novel psychoactive substances (NPS). Many of these abused drugs have unknown pharmacology, but their biological effects can be anticipated from their molecular structure and possibly also from online user reports. When considered with the findings that some prescription medications are increasingly abused and that some abused drugs have been tested clinically one could argue that there has been a blurring of the line between drugs of abuse and clinically used drugs. In this review we examine these legal highs/NPS and consider whether, based on their known or predicted pharmacology, some might have the potential to be clinically useful in CNS disorders.

Saturday night fever in ecstasy/MDMA dance clubbers: Heightened body temperature and associated psychobiological changes

Aims and rationale: to investigate body temperature and thermal self-ratings of Ecstasy/MDMA users at a Saturday night dance club.

METHODS

68 dance clubbers (mean age 21.6 years, 30 females and 38 males), were assessed at a Saturday night dance club, then 2-3 d later. Three subgroups were compared: 32 current Ecstasy users who had taken Ecstasy/MDMA that evening, 10 abstinent Ecstasy/MDMA users on other psychoactive drugs, and 26 non-user controls (predominantly alcohol drinkers). In a comparatively quiet area of the dance club, each unpaid volunteer had their ear temperature recorded, and completed a questionnaire on thermal feelings and mood states. A similar questionnaire was repeated 2-3 d later by mobile telephone.

RESULTS

Ecstasy/MDMA users had a mean body temperature 1.2°C higher than non-user controls (P < 0.001), and felt significantly hotter and thirstier. The abstinent Ecstasy/MDMA polydrug user group had a mean body temperature intermediate between the other 2 groups, significantly higher than controls, and significantly lower than current Ecstasy/MDMA users. After 2-3 d of recovery, the Ecstasy/MDMA users remained significantly 'thirstier'. Higher body temperature while clubbing was associated with greater Ecstasy/MDMA usage at the club, and younger age of first use. Higher temperature also correlated with lower elation and poor memory 2-3 d later. It also correlated positively with nicotine, and negatively with cannabis.

CONCLUSIONS

Ecstasy/MDMA using dance clubbers had significantly higher body temperature than non-user controls. This heightened body temperature was associated with a number of adverse psychobiological consequences, including poor memory.

Social contacts and Ecstasy offers: findings of a population-based study

Ecstasy (MDMA) use is relatively common among young adults in many developed countries. However, little is known about how young non-users are first introduced to Ecstasy, including the relative contribution of peer networks and individual risk factors. We assess the role of social contact with Ecstasy-using peers in regard to young adults' exposure to offers of Ecstasy, using data from the Natural History Study, a population-based study conducted in Australia. Population screening of young adults (19- to 23-year-olds) identified a sample of young Ecstasy users (N = 315) and a comparison group of Ecstasy-naïve participants (N = 199). Two outcomes are considered: being exposed to any Ecstasy offers and being exposed to > 3 offers. Extensive social contact with Ecstasy users was defined as knowing > 10 Ecstasy users. Of the Ecstasy-naïve young adults, > 40% had ever received Ecstasy offers. Extensive social contact with Ecstasy users independently predicted exposure to multiple (> 3) Ecstasy offers for Ecstasy-naïve young adults. These findings indicate that Ecstasy offers are widespread among users and non-users of Ecstasy. For non-users, exposure to Ecstasy offers occurs through social contact with drug-using peers independently of individual risk factors. The pervasiveness of Ecstasy offers suggests that universal education concerning Ecstasy use is required.

MDMA and heightened cortisol: a neurohormonal perspective on the pregnancy outcomes of mothers used 'Ecstasy' during pregnancy

OBJECTIVE

The illicit recreational drug 3,4-methylenedioxymethamphetamine (MDMA) or Ecstasy has strong neurohormonal effects. When taken by recreational users at dance clubs and raves, it can generate an 800% increase in the stress hormone cortisol, whereas drug-free users show chronically raised levels of cortisol. The aim here is to critically debate this neurohormonal influence for the children of pregnant MDMA-using mothers.

METHODS

High levels of cortisol are known to be damaging for neuropsychobiological well-being in adult humans. MDMA can damage foetal development in laboratory animals, and the prospective Drugs and Infancy Study was established to monitor the effects of MDMA taken recreationally by pregnant women.

RESULTS

The Drugs and Infancy Study revealed that young mothers, who took MDMA during the first trimester of pregnancy, gave birth to babies with significant gross psychomotor retardation. These mothers would have experienced high levels of cortisol due to Ecstasy/MDMA use, and since cortisol can cross the placenta, this is likely to have also occurred in the foetus.

CONCLUSIONS

In terms of causation, the developmental problems may reflect a combination of neurotransmitter and neurohormonal effects on the hypothalamic-pituitary-adrenal axis, with serotonergic activity being influenced by the high levels of cortisol.

Young adults' recreational social environment as a predictor of ecstasy use initiation: findings of a population-based prospective study

AIMS

To examine prospectively the contribution of the recreational social environment to ecstasy initiation.

DESIGN

Population-based retrospective/prospective cohort study.

SETTING

Data from screening an Australian young adult population to obtain samples of users and non-users of ecstasy.

PARTICIPANTS

A sample of 204 ecstasy-naive participants aged 19-23 years was obtained, and a 6-month follow-up identified those who initiated ecstasy use.

MEASUREMENTS

We assessed a range of predictors of ecstasy initiation, including elements of participants' social environment, such as ecstasy-using social contacts and involvement in recreational settings.

FINDINGS

More than 40% of ecstasy-naive young adults reported ever receiving ecstasy offers. Ecstasy initiation after 6 months was predicted independently by having, at recruitment, many ecstasy-using social contacts [adjusted relative risk (ARR) 3.15, 95% confidence interval (CI): 1.57, 6.34], attending electronic/dance music events (ARR 6.97, 95% CI: 1.99, 24.37), receiving an ecstasy offer (ARR 4.02, 95% CI: 1.23, 13.10), early cannabis use (ARR 4.04, 95% CI: 1.78, 9.17) and psychological distress (ARR 5.34, 95% CI: 2.31, 12.33). Adjusted population-attributable fractions were highest for ecstasy-using social contacts (17.7%) and event attendance (15.1%).

CONCLUSIONS

In Australia, ecstasy initiation in early adulthood is associated predominantly with social environmental factors, including ecstasy-using social contacts and attendance at dance music events, and is associated less commonly with psychological distress and early cannabis use, respectively. A combination of universal and targeted education programmes may be appropriate for reducing rates of ecstasy initiation and associated harms.

Novel psychoactive substances as a novel challenge for health professionals: results from an Italian survey

INTRODUCTION

Novel psychoactive substances (NPS; a.k.a. 'legal highs' or 'smart drugs') are advertised online as 'safe' and 'legal' natural/synthetic analogues of controlled illicit drugs. However, only little research has been carried out in identifying the health professionals' knowledge and expertise relating to the intake of these compounds.

METHODS

Data presented here refer to the Italian component of the European Union-wide, European Commission-funded, ReDNet project survey. An ad-hoc questionnaire was administered to professionals from the departments of Addiction, Psychiatry, Paediatrics and Emergency Room Services in Italy.

RESULTS

The interviewees' sample included 243 professionals, mostly from the departments of Addiction (35%) and Psychiatry (28.4%). Overall, interviewees self-reported a poor technical knowledge relating to NPS; some 27% of respondents confirmed of not being aware if their patients presented with a previous history of NPS misuse.

DISCUSSION

Novel psychoactive substances prevalence of misuse was not considered to be an unusual phenomenon in Italy, and most health professionals appeared to have concerns relating to associated medical and psychopathological risks, especially in terms of aggression/psychomotor agitation. Overall, most respondents reported the need to have better access to NPS-related reliable sources of information.

Precursors and Prices

Few analyses of basic elements of the synthetic drug market have been conducted, particularly in regard to its structural features. Synthetic drug’s relatively recent classification as an illicit substance, coupled with its distinct clandestine characteristics, has hindered the development of reliable assessments of the market’s structural features. Using information derived from 365 seized synthetic drugs, this study aims to reliably examine the structural attributes of Quebec’s synthetic drug market by merging two approaches: drug composition and economic analysis. Findings for the drug composition analysis indicate that the market is composed of a high number of small structures, indicating a competitive and decentralized market. Providing complementary information, the economic analysis revealed that differential production costs and relations between traffickers influence price variations, depending on the region. These results emphasize the need to design policies that account for regional differences as well as reflect the competitive nature of the market.

Roles of 3,4-methylenedioxymethamphetamine (MDMA)-induced alteration of connexin43 and intracellular Ca(2+) oscillation in its cardiotoxicity

Although it is well known that 3,4-methylenedioxymethamphetamine (MDMA) can cause various cardiovascular abnormalities and even sudden death from cardiac arrhythmia, whether it has any effect on myocardial gap junctions, which might be one of the targets mediating MDMA-induced cardiotoxicity, remains unclear.

OBJECTIVE

To test the hypothesis that MDMA may affect the myocardial gap junction protein connexin43 (Cx43) and induce cardiac dysrhythmia.

METHOD

(1) In vivo study: adult rats were treated with a single dose MDMA administration (20mg/kg, i.p.). Electrocardiogram detection and immunohistochemical analysis were performed to evaluate cardiac function and expression of Cx43, respectively; (2) in vitro study: cultured ventricular myocytes of neonatal rats were treated with MDMA (10, 100, 1000μmol/L) for 1h. Western blotting and real-time quantitative polymerase chain reaction (RT-qPCR) were performed to investigate the total Cx43 mRNA expression. Immunofluorescent analysis was used to evaluate the amount of junctional Cx43. The phosphorylation status of Cx43 at site Ser368 and intracellular Ca(2+) oscillation were also studied.

RESULTS

Obvious changes in electrocardiographic patterns were found in rats following MDMA administration. They were characterized by prolonged QRS duration associated with increased amplitude of QRS complex. The heart rates in treated rats were significantly decreased compared to the rats in the control group. The immunohistochemical findings revealed a significant decrease in Cx43 expression. The in vitro study also showed a marked decline in total Cx43 protein associated with reduction of Cx43 mRNA, whereas the phosphorylated Cx43 at Ser368 was increased. Decrease of junctional Cx43 was found correlated with reduction in N-cadherin induced by high concentration of MDMA. Additionally, confocal microscopy findings revealed alteration of intracellular calcium oscillation patterns characterized by high frequency and increasing influx Ca(2+).

CONCLUSIONS

MDMA reduces expression of cardiac gap junction protein Cx43. The increase of phosphorylation status of Cx43 at Ser368 induced by MDMA is attributed, at least in part, to the Ca(2+)-dependent regulation of protein kinase C (PKC) activity. Our findings provide first evidence of MDMA-mediated changes in those cardiac gap junctions that may underlie MDMA-induced cardiac arrhythmia.

Alcohol and drugs in epilepsy: pathophysiology, presentation, possibilities, and prevention

The potentially serious outcomes from ingestion of and dependence on toxins make this an important topic for epileptologists. We must be aware of the potential for harm from compounds that may be freely available, yet patients may try to conceal their use. Problematic compounds may cause seizures either acutely or on withdrawal: Their use may reduce effectiveness of antiepileptic drugs, or may simply promote and enhance chaotic lifestyles. Any or all of these factors may worsen seizure control or even directly cause seizures. This article highlights the pathophysiology behind provoked seizures, provides clues to diagnosis, and then outlines the steps that clinicians should take to reduce the deleterious effects of toxic compounds.

Memantine attenuates 3,4-methylenedioxymethamphetamine-induced hyperthermia in rats

3,4-Methylenedioxymethamphetamine (MDMA) is an illegal drug that can induce life-threatening hyperthermia. No effective pharmacological treatment for MDMA-induced hyperthermia has yet been established. We investigated the effects of memantine, a non-competitive N-methyl-D-aspartate (NMDA)-type glutamate receptor antagonist and an α-7 nicotinic acetylcholine receptor (nAChR) antagonist, on MDMA-induced hyperthermia in rats. Treatment of animals with memantine (10 or 20 mg/kg) either before or after MDMA (10 mg/kg) administration significantly decreased the peak body temperature. Results from our microdialysis study indicated that pretreatment with memantine (20 mg/kg) before MDMA administration had no effect on the MDMA-induced increase in serotonin (5-HT) and dopamine (DA) levels in the anterior hypothalamus. MDMA-induced hyperthermia was significantly suppressed by pretreatment with the non-competitive NMDA receptor antagonist MK-801 (0.5 mg/kg) and the competitive NMDA antagonist CGS 19755 (5 mg/kg), but not by the selective α-7 nAChR antagonist methyllycaconitine (6 or 10 mg/kg). These results indicate that the inhibitory effect of memantine on MDMA-induced hyperthermia may be due to its activity as an NMDA receptor antagonist and not as a result of a direct effect on the 5-HT or DA systems. The present study suggests that moderate doses of memantine may be useful for the treatment of MDMA-induced hyperthermia in humans.

Linking the pharmacological content of ecstasy tablets to the subjective experiences of drug users

RATIONALE

Most studies on the subjective effects of ecstasy are based on the assumption that the substance that was taken is 3,4-methylenedioxymethamphetamine (MDMA). However, many tablets sold as ecstasy contain other substances and MDMA in varying doses. So far, few attempts have been made to take this into account while assessing subjective effects.

OBJECTIVES

This study aims to link the pharmacological content of tablets sold as ecstasy to the subjective experiences reported by ecstasy users.

METHODS

Self-reported effects on ecstasy tablets were available from 5,786 drug users who handed in their tablets for chemical analysis at the Drug Information and Monitoring System (DIMS) in the Netherlands. Logistic regression was employed to link the pharmacological content of ecstasy tablets to the self-reported subjective effects and compare effects with MDMA to other substances present.

RESULTS

MDMA showed a strong association with desirable subjective effects, unparalleled by any other psychoactive substance. However, the association of MDMA was dose-dependent, with higher doses (>120 mg/tablet) likely to evoke more adverse effects. The novel psychostimulants mephedrone and p-fluoroamphetamine were considered relatively desirable, whereas meta-chlorophenylpiperazine (mCPP) and p-methoxymethamphetamine (PMMA) were strongly associated with adverse subjective effects. Also, 3,4-methylene-dioxyamphetamine (MDA) and benzylpiperazine (BZP) were not appreciated as replacement for MDMA.

CONCLUSION

Linking the pharmacological content of ecstasy sold on the street to subjective experiences contributes to a better understanding of the wide range of subjective effects ascribed to ecstasy and provides a strong rationale for the prolonged endurance of MDMA as the key ingredient of the ecstasy market.

Ecstasy (MDMA)-induced hyponatraemia is associated with genetic variants in CYP2D6 and COMT

We hypothesised that genetically determined poor metabolism of 3,4-methylene dioxymetamphetamine (MDMA) due either to the presence of CYP2D6 genotypes giving absent or low CYP2D6 enzyme activity, or a COMT genotype predicting low COMT enzyme activity would be associated with a greater degree of MDMA-induced reduction in plasma sodium and osmolality than other genotypes at these genes following consumption of 'ecstasy' tablets by clubbers. Of the 48 subjects who returned to the test site post-clubbing, 30 provided samples for measurement of vasopressin (AVP), plasma sodium, urea and plasma and urine osmolality. Genotyping was performed for functional variants in CYP2D6 (n = 29) and COMT (Val158Met, n = 30). In subjects with urinary MDMA detected post-clubbing, there was a significant association between change in plasma osmolality (p = 0.009) and in plasma sodium (p = 0.012) and CYP2D6 genotypic category. Individuals with the low-activity but readily inhibitable CYP2D6 extensive metaboliser/intermediate metaboliser (EM/IM) genotype showed greater reductions in these measures than all other CYP2D6 genotypic categories. COMT low-activity genotypes (Met/Met and Val/Met) were also significantly associated with reductions in plasma osmolality (p = 0.028) and in plasma sodium (p = 0.003). On conservative Bonferroni correction for two independent genes, the CYP2D6 and COMT plasma sodium findings remain significant. The relatively high frequency of the low-activity CYP2D6 and COMT genotypes in the population warrants further attention, since consumption of free water following ingestion of MDMA in these individuals may trigger dilutational hyponatraemia and increased risk of syndrome of inappropriate antidiuretic hormone secretion.

MDMA and temperature: a review of the thermal effects of 'Ecstasy' in humans

AIMS

To review the thermal effects of MDMA in humans, and discuss the practical implications.

METHODS

The literature on Ecstasy/MDMA, body temperature, and subjective thermal self-ratings was reviewed, and explanatory models for the changes in thermal homeostasis were examined and debated.

RESULTS

In human placebo-controlled laboratory studies, the effects of MDMA were dose related. Low doses had little effect, moderate doses increased body temperature by around +0.4°C, and higher doses caused a mean increase of +0.7°C. With Ecstasy/MDMA using dance clubbers, the findings showed greater variation, due possibly to uncontrolled factors such as physical activity, ambient temperature, and overcrowding. Some real world studies found average body temperature increases of over +1.0°C. Thermal homeostasis involves a balance between heat production and heat dissipation, and MDMA affects both aspects of this homeostatic equation. Cellular metabolic heat output is increased, and heat dissipation mechanisms are stressed, with the onset of sweating delayed. Subjective responses of 'feeling hot' or 'hot-cold flushes' are frequent, but can show individual variation. Some recreational users report that heat increases or reinstates the positive mood effects of Ecstasy/MDMA. The dangers of acute hyperthermia can include rare fatalities. It is unclear why moderate hyperthermia can occasionally progress to severe hyperpyrexia, although it may reflect a combination or cascade of events. In chronic terms, the bioenergetic stress model notes that the adverse psychobiological effects of MDMA are heightened by various co-stimulatory factors, including heat stress.

CONCLUSIONS

MDMA increases core body temperature and thermal stress in humans.

Psychostimulant-related deaths among former inmates

OBJECTIVES

Psychostimulants are highly addictive and their use is increasing. Little is known about psychostimulant-related deaths. This study identified characteristics, risk factors, and contributing substances reported upon death among former prison inmates who died from a psychostimulant-related death.

METHODS

This retrospective cohort study of released inmates from 1999 to 2003 (N = 30,237) linked data from the Washington State Department of Corrections with the National Death Index. We examined characteristics of individuals who died with psychostimulants listed among their causes of death. These were categorized into 3 groups: (1) noncocaine psychostimulants, (2) cocaine only, and (3) all psychostimulants. Cox proportional hazards regression determined risk factors for death in each group, and the risk of death in the first 2 weeks after release from prison

RESULTS

Of the 443 inmates who died, 25 (6%) had noncocaine psychostimulants listed among their causes of death. Six of these 25 deaths had both noncocaine psychostimulants and cocaine listed among their causes-of-death. Most of the former inmates who died with noncocaine psychostimulants were male (n = 21, 84%) and non-Hispanic white (88%, n = 22). Cocaine only was listed among the causes-of-death for 49 former inmates; most were male (n = 35, 71%) and non-Hispanic white (n = 27, 55%). Longer length of incarceration was associated with a reduced risk of death from any psychostimulant use (hazard ratio = 0.76, confidence interval = 0.63-0.920 for each additional year of incarceration) and from use of noncocaine psychostimulants (hazard ratio = 0.42, 95% CI = 0.22-0.80). Risk of death was highest during the first 2 weeks postrelease for cocaine only-related deaths (incidence mortality ratio = 1224.0, confidence interval = 583-1865).

CONCLUSIONS

Former prisoners have a significant risk of death from psychostimulants, especially within the first 2 weeks postrelease.

Mechanisms of MDMA (ecstasy)-induced oxidative stress, mitochondrial dysfunction, and organ damage

Despite numerous reports about the acute and sub-chronic toxicities caused by MDMA (3,4-methylenedioxymethamphetamine, ecstasy), the underlying mechanism of organ damage is poorly understood. The aim of this review is to present an update of the mechanistic studies on MDMA-mediated organ damage partly caused by increased oxidative/nitrosative stress. Because of the extensive reviews on MDMA-mediated oxidative stress and tissue damage, we specifically focus on the mechanisms and consequences of oxidative-modifications of mitochondrial proteins, leading to mitochondrial dysfunction. We briefly describe a method to systematically identify oxidatively-modified mitochondrial proteins in control and MDMA-exposed rats by using biotin-N-maleimide (biotin-NM) as a sensitive probe for oxidized proteins. We also describe various applications and advantages of this Cys-targeted proteomics method and alternative approaches to overcome potential limitations of this method in studying oxidized proteins from MDMA-exposed tissues. Finally we discuss the mechanism of synergistic drug-interaction between MDMA and other abused substances including alcohol (ethanol) as well as application of this redox-based proteomics method in translational studies for developing effective preventive and therapeutic agents against MDMA-induced organ damage.

Increased oxidative-modifications of cytosolic proteins in 3,4-methylenedioxymethamphetamine (MDMA, ecstasy)-exposed rat liver

It is well established that 3,4-methylenedioxymethamphetamine (MDMA, ecstasy) causes acute liver damage in animals and humans. The aim of this study was to identify and characterize oxidative modification and inactivation of cytosolic proteins in MDMA-exposed rats. Markedly increased levels of oxidized and nitrated cytosolic proteins were detected 12 h after the second administration of two consecutive MDMA doses (10 mg/kg each). Comparative 2-DE analysis showed markedly increased levels of biotin-N-methylimide-labeled oxidized cytosolic proteins in MDMA-exposed rats compared to vehicle-treated rats. Proteins in the 22 gel spots of strong intensities were identified using MS/MS. The oxidatively modified proteins identified include anti-oxidant defensive enzymes, a calcium-binding protein, and proteins involved in metabolism of lipids, nitrogen, and carbohydrates (glycolysis). Cytosolic superoxide dismutase was oxidized and its activity significantly inhibited following MDMA exposure. Consistent with the oxidative inactivation of peroxiredoxin, MDMA activated c-Jun N-terminal protein kinase and p38 kinase. Since these protein kinases phosphorylate anti-apoptotic Bcl-2 protein, their activation may promote apoptosis in MDMA-exposed tissues. Our results show for the first time that MDMA induces oxidative-modification of many cytosolic proteins accompanied with increased oxidative stress and apoptosis, contributing to hepatic damage.

An index of fatal toxicity for drugs of misuse

OBJECTIVE

To determine the lethal toxicity of five commonly-used illicit substances by relating the number of associated deaths to their availability.

METHODS

An index of toxicity was calculated for each of five drugs [heroin, cocaine/crack, ecstasy (MDMA), amphetamine and cannabis] as the ratio of the number of deaths associated with that substance to its availability in the period 2003-2007. Three separate proxy measures of availability were used (number of users as determined by household surveys, number of seizures by law enforcement agencies and estimates of the market size). All data are related to England and Wales only.

RESULTS

There was a broad correlation between all three denominators of availability. Not unexpectedly, heroin and cannabis showed, respectively, the highest and lowest toxicities. The index of fatal toxicity of MDMA was close to that of amphetamine and cocaine/crack. There was a rank correlation between this index and other measures of lethal toxicity based on safety ratios.

CONCLUSIONS

These results are contrary to widely-held public views of the relative fatal toxicity of MDMA.

Cortisol and 3,4-methylenedioxymethamphetamine: neurohormonal aspects of bioenergetic stress in ecstasy users

AIMS

3,4-Methylenedioxymethamphetamine (MDMA) can affect both neurotransmitter and neurohormonal activity. This review will debate the role of the metabolic activation hormone cortisol for the psychobiological effects of ecstasy/MDMA.

METHODS

The empirical literature on cortisol release following acute MDMA administration and cortisol functioning in drug-free recreational ecstasy/MDMA users will be reviewed. This will be followed by an overview of cortisol as a bioenergetic stress neurohormone, and a debate on how it could be modulating the acute and chronic psychobiological effects of MDMA.

RESULTS

Cortisol release is increased by stimulatory factors, including physical activity, thermal stress and stimulant drugs. In laboratory studies MDMA leads to an acute cortisol increase of around 150% in sedentary humans. In MDMA-using dance clubbers, the cortisol levels are increased by around 800%, possibly due to the combined factors of stimulant drug, physical exertion and psychosocial stimulation. Regular ecstasy/MDMA users also demonstrate changes in baseline cortisol levels and cortisol reactivity, with compromised hypothalamic-pituitary-adrenal activity. Nonpharmacological research has shown how cortisol is important for psychological aspects such as memory, cognition, sleep, impulsivity, depression and neuronal damage. These same functions are often impaired in recreational ecstasy/MDMA users, and cortisol may be an important modulatory co-factor.

CONCLUSIONS

The energizing hormone cortisol is involved in the psychobiology of MDMA, probably via its effects on energy metabolism. Acute cortisol release may potentiate the stimulating effects of MDMA in dance clubbers. Chronically, cortisol may contribute to the variance in functional and structural consequences of repeated ecstasy usage.

Methylenedioxymethamphetamine (MDMA)-related fatalities in Australia: demographics, circumstances, toxicology and major organ pathology

AIM

To examine the demographic characteristics, circumstances, toxicology and major organ pathology of MDMA-related deaths in Australia.

METHODS

Retrospective review of cases in which MDMA was a cause of death, as identified from the National Coronial Information System.

RESULTS

82 cases over a 5-year period were identified. The majority of decedents were male (83%), with a median age of 26 years. Deaths were predominantly due to drug toxicity (82%), with MDMA the sole drug causing death in 23% of cases, and combined drug toxicity in 59% of cases. The remaining deaths (18%) were primarily due to pathological events/disease or injury, with MDMA a significant contributing condition. Cardiovascular pathology, typically atherosclerosis, was detected in 58% of decedents, with moderate-severe atherosclerosis in 23% of cases. The prevalence of such pathology is higher than that expected among similarly aged members of the general population. Cerebrovascular pathology, primarily cerebral haemorrhage and hypoxic damage, was present in 12% of cases.

CONCLUSIONS

MDMA has contributed to a clinically significant number of deaths in Australia. The prevalence of cardiovascular pathology was similar to that among methamphetamine and cocaine fatalities. Whilst cardiovascular pathology may reflect the use of other stimulants, the cardiotoxic properties of MDMA have been well-documented. Future studies examining MDMA-related morbidity and mortality in the context of other risk factors are recommended. Overall, the current study highlights the need to educate users about the potential harms of MDMA use, particularly that in conjunction with other stimulants, opioids and alcohol, which are known to increase overall toxicity.

Mechanism of 3,4-methylenedioxymethamphetamine (MDMA, ecstasy)-mediated mitochondrial dysfunction in rat liver

Despite numerous reports citing the acute hepatotoxicity caused by 3,4-methylenedioxymethamphetamine (MDMA) (ecstasy), the underlying mechanism of organ damage is poorly understood. We hypothesized that key mitochondrial proteins are oxidatively modified and inactivated in MDMA-exposed tissues. The aim of this study was to identify and investigate the mechanism of inactivation of oxidatively modified mitochondrial proteins, prior to the extensive mitochondrial dysfunction and liver damage following MDMA exposure. MDMA-treated rats showed abnormal liver histology with significant elevation in plasma transaminases, nitric oxide synthase, and the level of hydrogen peroxide. Oxidatively modified mitochondrial proteins in control and MDMA-exposed rats were labeled with biotin-N-maleimide (biotin-NM) as a sensitive probe for oxidized proteins, purified with streptavidin-agarose, and resolved using 2-DE. Comparative 2-DE analysis of biotin-NM-labeled proteins revealed markedly increased levels of oxidatively modified proteins following MDMA exposure. Mass spectrometric analysis identified oxidatively modified mitochondrial proteins involved in energy supply, fat metabolism, antioxidant defense, and chaperone activities. Among these, the activities of mitochondrial aldehyde dehydrogenase, 3-ketoacyl-CoA thiolases, and ATP synthase were significantly inhibited following MDMA exposure. Our data show for the first time that MDMA causes the oxidative inactivation of key mitochondrial enzymes which most likely contributes to mitochondrial dysfunction and subsequent liver damage in MDMA-exposed animals.

A validated gas chromatographic-electron impact ionization mass spectrometric method for methamphetamine, methylenedioxymethamphetamine (MDMA), and metabolites in mouse plasma and brain

A method was developed and fully validated for simultaneous quantification of methamphetamine (MAMP), amphetamine, hydroxy-methamphetamine, methylenedioxymethamphetamine (MDMA, ecstasy), methylenedioxyamphetamine, 3-hydroxy-4-methoxy-methamphetamine, and 3-hydroxy-4-methoxy-amphetamine in 100 microL mouse plasma and 7.5mg brain. Solid phase extraction and gas chromatography-electron impact ionization mass spectrometry in selected-ion monitoring mode achieved plasma linear ranges of 10-20 to 20,000 ng/mL and 0.1-0.2 to 200 ng/mg in brain. Recoveries were greater than 91%, bias 92.3-110.4%, and imprecision less than 5.3% coefficient of variation. This method was used for measuring MAMP and MDMA and metabolites in plasma and brain during mouse neurotoxicity studies.

Synergistic toxicity of ethanol and MDMA towards primary cultured rat hepatocytes

Ethanol is frequently consumed along with 3,4-methylenedioxymethamphetamine (MDMA; ecstasy). Since both compounds are hepatotoxic and are metabolized in the liver, an increased deleterious interaction resulting from the concomitant use of these two drugs seems plausible. Another important feature of MDMA-induced toxicity is hyperthermia, an effect known to be potentiated after continuous exposure to ethanol. Considering the potential deleterious interaction, the aim of the present study was to evaluate the hepatotoxic effects of ethanol and MDMA mixtures to primary cultured rat hepatocytes and to elucidate the mechanism(s) underlying this interaction. For this purpose, the toxicity induced by MDMA to primary cultured rat hepatocytes in absence or in presence of ethanol was evaluated, under normothermic (36.5 degrees C) and hyperthermic (40.5 degrees C) conditions. While MDMA and ethanol, by themselves, had discrete effects on the analysed parameters, which were slightly aggravated under hyperthermia, the simultaneous incubation of MDMA and ethanol for 24h, resulted in high cell death ratios accompanied by a significant disturbance of cellular redox status and decreased energy levels. Evaluation of apoptotic/necrotic features provided clear evidences that the cell death occurs preferentially through a necrotic pathway. All the evaluated parameters were dramatically aggravated when cells were incubated under hyperthermia. In conclusion, co-exposure of hepatocytes to ethanol and MDMA definitely results in a synergism of the hepatotoxic effects, through a disruption of the cellular redox status and enhanced cell death by a necrotic pathway in a temperature-dependent extent.

Severe Ecstasy poisoning in an 8-month-old infant

We report on an 8-month-old male infant who accidentally ingested an Ecstasy tablet (3,4-methylenedioxymetamphetamine, MDMA). Here we discuss, according to the available literature, the treatment, complications, and pharmacokinetics of MDMA intoxication in a young infant. Serum MDMA level 2 hours after ingestion was with 785 ng x mL(-1) above the dose considered lethal for adults (>500 ng x mL(-1)). After ingestion the patient showed life-threatening tachycardia of 210 beats min(-1), hyperthermia of 38.9 degrees C, seizures, and hypertension of 125/70 mmHg. Under supportive treatment (benzodiazepine, body cooling, rehydration therapy), 6 hours after admission, body temperature as well as the elevated blood pressure and heart beat had returned to normal values. Nine hours after ingestion the serum MDMA level was still 274 ng x mL(-1). The patient made a full clinical recovery and afterwards appeared to be a healthy boy. This case illustrates the need to consider the possibility of accidental Ecstasy ingestion in the differential diagnosis of a child suffering from convulsions with fever.

Developmental effects of 3,4-methylenedioxymethamphetamine: a review

+/-3,4-Methylenedioxymethamphetamine (MDMA) is a chemical derivative of amphetamine that has become a popular drug of abuse and has been shown to deplete serotonin in the brains of users and animals exposed to it. To date, most studies have investigated the effects of MDMA on adult animals. With a majority of users of MDMA being young adults, the chances of the users becoming pregnant and exposing the fetuses to MDMA are also a concern. Evidence to date has shown that developmental exposure to MDMA results in learning and memory impairments in the Morris water maze, a task known to be sensitive to hippocampal disruption, when the animals are tested as adults. Developmental MDMA exposure leads to hypoactivity in the offspring as adults but does not affect outcome on tests of anxiety. MDMA administration decreases pup weight, increases corticosterone and brain-derived neurotrophic factor levels during treatment while decreasing brain levels of serotonin; a decrease that initially dissipates and then reappears in adulthood. Neonatal MDMA exposure increases the sensitivity of the serotonin 1A receptor, a possible mechanism underlying the learning and memory deficits seen. Taken together, the evidence shows that MDMA exposure has adverse effects on the developing brain and behavior. The animal and human data on developmental MDMA exposure are reviewed and their public health implications discussed.

Tolerance to 3,4-methylenedioxymethamphetamine in rats exposed to single high-dose binges

3,4-Methylenedioxymethamphetamine (MDMA or ecstasy) stimulates the transporter-mediated release of monoamines, including 5-HT. High-dose exposure to MDMA causes persistent 5-HT deficits (e.g. depletion of brain 5-HT) in animals, yet the functional and clinical relevance of such deficits are poorly defined. Here we examine functional consequences of MDMA-induced 5-HT depletions in rats. Male rats received binges of three i.p. injections of MDMA or saline, one injection every 2 h; MDMA was given at a threshold pharmacological dose (1.5 mg/kgx3, low dose) or at a fivefold higher amount (7.5 mg/kgx3, high dose). One week later, jugular catheters and intracerebral guide cannulae were implanted. Two weeks after binges, rats received acute i.v. challenge injections of 1 and 3 mg/kg MDMA. Neuroendocrine effects evoked by i.v. MDMA (prolactin and corticosterone secretion) were assessed via serial blood sampling, while neurochemical effects (5-HT and dopamine release) were assessed via microdialysis in brain. MDMA binges elevated core temperatures only in the high-dose group, with these same rats exhibiting approximately 50% loss of forebrain 5-HT 2 weeks later. Prior exposure to MDMA did not alter baseline plasma hormones or dialysate monoamines, and effects of i.v. MDMA were similar in saline and low-dose groups. By contrast, rats pretreated with high-dose MDMA displayed significant reductions in evoked hormone secretion and 5-HT release when challenged with i.v. MDMA. As tolerance developed only in rats exposed to high-dose binges, hyperthermia and 5-HT depletion are implicated in this phenomenon. Our results suggest that MDMA tolerance in humans may reflect 5-HT deficits which could contribute to further dose escalation.

Cocaine/crack cocaine consumption, treatment demand, seizures, related offences, prices, average purity levels and deaths in the UK (1990 - 2004)

A recent trend of escalating use of cocaine/crack cocaine was observed in the UK. The number of mentions on death certificates; last year use of cocaine; treatment demand, number of drug offenders, seizures, prices and average purity levels were the indicators used for this descriptive and correlational study. Figures (1990-2004) were taken from official UK sources. A total of 1022 cocaine/crack cocaine death mentions (i.e. deaths from any cause where the presence of cocaine/crack cocaine was also detected) were identified, with cocaine/crack cocaine being the sole drug mentioned in 36% of cases. The number of cocaine/crack cocaine death mentions showed a year-on-year increase and correlated positively with the following cocaine (powder) figures: last year use (p < 0.001); number of offenders (p < 0.001) and number of seizures (p < 0.001), but correlated negatively with price (p < 0.001). Furthermore, the number of cocaine/crack cocaine death mentions correlated positively with the number of crack offenders (p < 0.001) and seizures (p < 0.001), but correlated negatively with both crack purity ( p < 0.001) and price (p < 0.05). With conditions of increasing drug availability having been met in the UK, decrease in cocaine prices were associated with higher consumption levels and this, in turn, contributed to the increase in number of cocaine-related fatalities. There are limitations with the information collected, since no distinction is usually made on medical death certificates between cocaine and crack cocaine. The present study being an ecological one, it proved difficult to address the role of confounding variables that may well explain some of the associations observed.

Sensation seeking, attitudes toward drug use, and actual use among adolescents: testing a model for alcohol and ecstacy use

The use of ecstasy (MDMA), one of the most popular substances among young people in the context of many leisure and fun activities, is moving from party and recreation circuits to high schools and college dorms, in many cases in combination with alcohol consumption. Bearing in mind the concurrent use of the two drugs and the "gateway" thesis of a progression from legal drugs to illegal ones, a causal(1) model of linkages among sensation seeking, attitudes toward alcohol and ecstasy consumption, and frequency of use was tested using structural equation modeling (SEM). The data were obtained from a sample of 450 high school students ranging in age from 14 to 18 (47% male, 53% female). An additional moderator analysis was performed in order to examine a possible moderating role of sensation seeking in the relationship between attitudes toward consumption and frequency of use of both alcohol and ecstasy. Results were consistent with the hypothesis that positive attitudes toward consumption mediate the effects of sensation seeking on drug use. In addition, whereas our results were coherent with the existence of direct effects of sensation seeking on drug use, these were only found in the case of alcohol consumption. However, a moderating effect of this same variable was observed in the relationship between positive attitudes toward ecstasy consumption and its frequency of use. General and specific clinical implications and limitations of these findings are discussed and future lines of research suggested. .

Comparative potencies of 3,4-methylenedioxymethamphetamine (MDMA) analogues as inhibitors of [3H]noradrenaline and [3H]5-HT transport in mammalian cell lines

BACKGROUND AND PURPOSE

Illegal 'ecstasy' tablets frequently contain 3,4-methylenedioxymethamphetamine (MDMA)-like compounds of unknown pharmacological activity. Since monoamine transporters are one of the primary targets of MDMA action in the brain, a number of MDMA analogues have been tested for their ability to inhibit [3H]noradrenaline uptake into rat PC12 cells expressing the noradrenaline transporter (NET) and [3H]5-HT uptake into HEK293 cells stably transfected with the 5-HT transporter (SERT).

EXPERIMENTAL APPROACH

Concentration-response curves for the following compounds at both NET and SERT were determined under saturating substrate conditions: 4-hydroxy-3-methoxyamphetamine (HMA), 4-hydroxy-3-methoxymethamphetamine (HMMA), 3,4-methylenedioxy-N-hydroxyamphetamine (MDOH), 2,5-dimethoxy-4-bromophenylethylamine (2CB), 3,4-dimethoxymethamphetamine (DMMA), 3,4-methylenedioxyphenyl-2-butanamine (BDB), 3,4-methylenedioxyphenyl-N-methyl-2-butanamine (MBDB) and 2,3-methylenedioxymethamphetamine (2,3-MDMA).

KEY RESULTS

2,3-MDMA was significantly less potent than MDMA at SERT, but equipotent with MDMA at NET. 2CB and BDB were both significantly less potent than MDMA at NET, but equipotent with MDMA at SERT. MBDB, DMMA, MDOH and the MDMA metabolites HMA and HMMA, were all significantly less potent than MDMA at both NET and SERT.

CONCLUSIONS AND IMPLICATIONS

This study provides an important insight into the structural requirements of MDMA analogue affinity at both NET and SERT. It is anticipated that these results will facilitate understanding of the likely pharmacological actions of structural analogues of MDMA.

Is there a case for MDMA-assisted psychotherapy in the UK?

Much has been written in scientific and popular literature in recent years about the dangers surrounding the recreational use of the drug MDMA/ecstasy. What is little known and understood however is the history of the apparently safe and effective use of MDMA as a therapeutic tool for psychotherapy. In this paper the author explores this history and describes the recent re-emergence of scientific interest in MDMA and other psychedelic drugs. There are currently several new double-blind randomised controlled trials underway re-visiting the subject. By acknowledging the limitations of this new research and emphasising the importance of exercising appropriate but realistic caution, the author asks that the medical profession consider a dispassionate and open-minded debate to examine whether MDMA might have a legitimate place as an adjunct to psychotherapy in modern psychiatric practice.