What is 3,4-Methylenedioxymethamphetamine (MDMA) Toxicity (Ecstasy (Molly) Overdose)?
MDMA, also known as 3,4-methylenedioxymethamphetamine, is a man-made drug that has been used recreationally since the 1980s. It’s known by several street names like “Ecstasy,” “Molly,” “E,” and so on. This drug has effects that induce intense happiness, recall of memories, and heightened senses. It was first created in 1912 and started to become popular for recreational use in the 1980s.
MDMA is part of a group of psychoactive substances, referred to as entactogens, which basically translates to “touching within.” This drug triggers feelings of extreme joy, recollection of memories that could have been forgotten, and sensations of intimacy, empathy, sensuality, and ease of communication. Despite these effects, in 1985, the U.S Food and Drug Administration (FDA) listed MDMA as a Schedule I drug under the Controlled Substance Act of 1970, indicating that it has a high potential for misuse and isn’t officially recognized for medical use. However, a noteworthy recent trial suggested that MDMA could be extremely beneficial in treating posttraumatic stress disorder (PTSD) when used along with psychotherapy, and its use for this purpose is now under consideration for FDA approval.
MDMA can be found in various forms like colorful tablets imprinted with logos, capsules, powder, or liquid, and is usually swallowed. However, it can also be sniffed after being crushed into powder. The drug’s impact on the heart, brain, kidneys, and liver can be dangerous, and hence it’s crucial for healthcare professionals, particularly those in emergency situations, to identify its toxicity.
What Causes 3,4-Methylenedioxymethamphetamine (MDMA) Toxicity (Ecstasy (Molly) Overdose)?
MDMA, considered a highly dangerous drug, can be toxic even if taken only once. It’s usually swallowed as a tablet, but it can also be crushed and inhaled. The doses can range from 50 mg to 200 mg per tablet. However, it’s crucial to note that what’s sold as ecstasy or molly often contains other substances such as MDEA (also known as “eve”), MDA (or “sally”), ephedrine, ketamine, paracetamol, and others. These additional substances can affect heart and blood flow and may increase the risk of harmful effects or toxicity, even from a single use, due to the unpredictability of the dosage and what’s actually in the drug.
Moreover, MDMA is frequently used alongside other recreational drugs, which can add to or change its toxic effects on the brain and heart. These combined effects can become even more dangerous when someone takes MDMA while physically active in a hot, humid setting. This can lead to severe overheating, dehydration, and a dangerously low level of sodium in the blood, often resembling the symptoms of a heat stroke.
Risk Factors and Frequency for 3,4-Methylenedioxymethamphetamine (MDMA) Toxicity (Ecstasy (Molly) Overdose)
MDMA use has varied over time and across age groups, from as young as eighth graders to college students and adults. There was a notable surge in MDMA use between the 1990s and early 2000s, with increases reported on college campuses and among school-age children. In the United States, emergency room visits due to MDMA increased dramatically from 1994 to 2002. Despite this growth, the number of new users fluctuated between 2002 and 2007, with decreasing counts in 2003 and an increase in 2006-2007.
- MDMA use surged from 16% to 24% between 1986 and 1990 on one college campus.
- There was a 69% spike in MDMA use among a national sample of college students between 1997 and 1999.
- Between 1999 and 2000, lifetime use among 8th graders grew from 2.7% to 4.3%, with a larger increase in 12th graders (8%-11%).
- Emergency room visits in the United States related to MDMA spiked from 253 to 4511 between 1994-2000.
- About 12.7% of US college students had used ecstasy once in their lifetime, according to a 2002 study.
- Between 1996 and 2002, MDMA use by adults aged 18-25 increased by more than 200%, according to a 2002 National Survey of Drug Use and Health.
Although the number of MDMA users grew significantly between the early 1990s and 2000s, the number of new users changed from 2002 to 2007. This figure dropped from 1.2 million in 2002 to 642,000 in 2003, before climbing again to 860,000 between 2006 and 2007.
- In 2011, approximately 14.5 million people aged 12 and older had used MDMA at least once in their lives, with around 900,000 using it for the first time that year.
- This figure rose to 17 million in 2013, with the highest usage among young adults aged 18 to 25.
MDMA use, despite being less common than cannabis, opioid, and other amphetamine use in the United States and globally, remains a considerable public health concern due to its harmful effects.
Signs and Symptoms of 3,4-Methylenedioxymethamphetamine (MDMA) Toxicity (Ecstasy (Molly) Overdose)
Acute MDMA toxicity exhibits signs similar to what occurs when someone takes too many amphetamines such as a fast heart rate, high blood pressure, heart rhythm problems, anxiety, agitation, hallucinations, seizures, dilated pupils, sweating, and high body temperature. However, MDMA has less stimulant effects and more serotonin-related effects compared to amphetamines and methamphetamines. At lower doses, users may experience increased muscle activity, like teeth grinding, restless legs, tight jaw, hyperactivity, insomnia, trouble focusing, and restlessness.
Serious, life-threatening complications can occur, including serotonin syndrome (a reaction due to high serotonin levels), heart rhythm problems, the rapid breakdown of muscle tissue, aortic dissection (tear in the large blood vessel branching off the heart), and bleeding inside the skull. Since MDMA is metabolized in the liver, severe liver damage can occur, leading to potential liver failure. Hyperactivity in the central nervous system can lead to an excessively excited state of confusion or seizures.
MDMA, a popular drug at music festivals or raves, when combined with intense physical activity and its effects, can lead to a dangerous increase in body temperature resembling heat stroke, causing the rapid breakdown of muscle tissue. Coupled with an increase in fluid intake and the syndrome of inappropriate diuretic syndrome (a condition that causes your body to produce a lot of urine), severe low sodium levels in the blood may occur, leading to swelling in the brain, seizures, and even death.
Testing for 3,4-Methylenedioxymethamphetamine (MDMA) Toxicity (Ecstasy (Molly) Overdose)
If someone is experiencing unusual symptoms, there are some immediate actions that health professionals can take. They can establish intravenous (IV) access, monitor vital signs, do a rapid glucose check, and perform a complete physical examination. A key diagnostic piece is also to measure the patient’s core body temperature and check for dangerously high levels of hyperthermia (over 105 °F or 40.5 °C).
After initial steps, the doctor will suggest several lab tests based on the patient’s symptoms. These tests include:
- A basic metabolic panel (BMP) to check for any abnormalities in the body’s electrolyte balance, issues with kidney function, and a condition called rhabdomyolysis that harms muscles.
- Liver function tests (LFTs) to ensure the liver isn’t failing.
- Electrocardiogram (EKG) to check for fast heart rhythms.
Other tests might be needed based on the situation such as a complete blood count, urinalysis, coagulation profile, chest X-rays, a CT scan of the head, or a lumbar puncture, particularly if someone has an altered mental state that can’t be easily explained.
Although a urine drug screen might seem helpful in cases where amphetamine use is suspected, these tests are not typically recommended because they very often produce false positive or false negative results. Essentially, a positive result only confirms that the patient used a certain amphetamine in the past few days, but it can’t tell whether the use was recent. Plus, even the most precise drug tests can confuse certain similar substances.
There are also some substances found in common medicines and treatments that can produce inaccurate results by causing false positives or negatives on these drug tests.
Treatment Options for 3,4-Methylenedioxymethamphetamine (MDMA) Toxicity (Ecstasy (Molly) Overdose)
When treating cardiovascular emergencies, some of the initial steps include heart monitoring, making sure the patient can breathe properly, and ensuring healthy blood circulation. For patients who are agitated, temporary physical restraint might be used, with the aim to discontinue its use quickly to prevent harmful outcomes such as worsening of muscle breakdown (rhabdomyolysis) and heat generation. If a patient’s core body temperature exceeds 105 °F (40.5 °C), this constitutes an immediate life-endangering condition and requires urgent treatment after evaluating the airway.
Such treatment of high body temperature includes calming the patient quickly to control their agitation and applying external measures to cool them down. Amazingly, a method like immersing the patient’s whole body in ice-water has been found effective in treating life-threatening high body temperature.
The main method of treating agitation caused by a sudden excess of amphetamine, a type of drug, in the body is through sedation using drugs like diazepam (10 mg) or lorazepam (2 mg) administered via an intravenous drip (IV). These medicines are chosen because of their predictable actions in the body, their wide margin of safety, and their anti-seizure properties. In situations where an IV infusion can’t be set up, injecting the sedative midazolam into a muscle works well instead. The important thing is to titrate the sedation, meaning adjusting the dose to achieve the optimal effect, until the patient is calm.
If a patient’s body temperature is too high or they are excessively agitated due to acute amphetamine toxicity, it can lead to rhabdomyolysis, where muscle tissues break down, releasing harmful substances into the bloodstream. Treating this condition is primarily supportive and involves giving IV fluids to make sure urine output is between 1 and 2 mL per kilogram of body weight per hour. Although making the urine more acidic can speed up elimination and decrease the half-life of amphetamines, it is generally not recommended. This is because it doesn’t reduce toxicity and it can even increase the risk of sudden kidney injury (AKI) from rhabdomyolysis. In severe cases, procedures like hemodialysis might be needed in patients with kidney failure, excessively high blood acidity, and high potassium levels. It’s worth noting that using a muscle relaxant called dantrolene is not advised for treating amphetamine-induced high body temperature, due to limited evidence of its efficacy and potential harmful side effects.
What else can 3,4-Methylenedioxymethamphetamine (MDMA) Toxicity (Ecstasy (Molly) Overdose) be?
When doctors are trying to figure out a diagnosis, they consider other conditions that could be causing the symptoms. In this case, some possibilities might be:
- Anticholinergic toxicity (a reaction to certain medications)
- Cholinergic toxicity (poisoning caused by substances that stimulate the nervous system)
- Neuroleptic malignant syndrome (a life-threatening reaction to antipsychotic drugs)
- Malignant hyperthermia (a severe reaction to certain drugs used during general anesthesia)
- Serotonin syndrome (an adverse drug reaction)
- Monoamine oxidase inhibitor toxicity (a reaction to a type of antidepressant)
- Meningitis (an infection of the protective coverings of the brain and spinal cord)
- Encephalitis (inflammation of the brain)
- Heatstroke (a condition caused by your body overheating)
- Heat exhaustion (a heat-related illness that can occur after you’ve been exposed to high temperatures)
- Rhabdomyolysis (a serious syndrome due to a direct or indirect muscle injury)
- Amphetamine toxicity (a reaction to a type of stimulant drug)
- Cocaine toxicity (a reaction to the illegal drug cocaine)
It’s crucial for doctors to consider all these potential conditions when making their diagnosis.
What to expect with 3,4-Methylenedioxymethamphetamine (MDMA) Toxicity (Ecstasy (Molly) Overdose)
The two leading causes of death related to MDMA or “Ecstasy” are overheating (hyperthermia) and low sodium levels (hyponatremia). Even though the effects can be quite severe, deaths caused by MDMA are quite rare according to medical literature. One of the difficulties in determining if MDMA is the cause of death is that often, the victims have taken other drugs along with it.
While fatal cases are few, long-term negative effects are a concern. Studies done on monkeys and through imaging techniques have shown that MDMA can potentially lead to harmful results. Monkeys treated with MDMA showed signs of loss of certain markers in serotonin axon terminals – the part of the brain cell used to send the chemicals that affect mood and other functions. This could lead to issues with emotion, memory, and complex cognitive processes.
Imaging studies (PET scans) on baboons and humans with a history of MDMA use also showed significant decreases in certain aspects of serotonin, an important brain chemical. There were also changes noted in specific areas of the brain such as the amygdala and neocortex. This has been associated with memory loss and thinking issues. There can also be effects on the cerebrovascular systems – the brain’s blood vessels – leading to a decrease in cognitive abilities, somewhat similar to what is seen in dementia.
Possible Complications When Diagnosed with 3,4-Methylenedioxymethamphetamine (MDMA) Toxicity (Ecstasy (Molly) Overdose)
MDMA toxicity can cause a range of complications:
- Neurologic complications: These can include confusion and seizures.
- Cardiovascular complications: MDMA can lead to heart rhythm problems, heart attacks, tears in the wall of the main artery that carries blood from the heart, and bleeding in the brain.
- Gastrointestinal complications: The drug can harm the liver severely, leading to liver failure in very severe cases.
- Renal complications: These could include a breakdown of muscle tissue that can lead to kidney failure.
- Endocrine complications: MDMA toxicity can cause the body to release large amounts of substances that regulate the water balance, leading to dangerously low sodium levels in the blood and seizures.
Patients may also experience life-threatening high body temperature that resembles heat stroke. Other complications can include increased physical movement or muscle activity, like jaw clenching or restless legs, hyperactivity, insomnia, difficulty focusing, and feelings of restlessness.
Preventing 3,4-Methylenedioxymethamphetamine (MDMA) Toxicity (Ecstasy (Molly) Overdose)
Educating patients is essential for them to understand the short-term and long-term dangers of using MDMA, commonly known as ecstasy. Many individuals wrongly believe that ecstasy is a harmless drug with minimal negative effects. However, people can quickly develop a tolerance to it. If they then start taking higher doses, they might suffer from health issues. These can include symptoms like overheating, irregular heart rhythms, and unstable blood pressure.
It’s also necessary for patients to understand the long-lasting mental health effects related to frequent ecstasy use. This drug has been linked to depression, paranoia, anxiety, and insomnia, that can last for years even after stopping the drug’s use. Additionally, studies suggest that people who use ecstasy might experience issues with focus and memory.
