Ecstasy-fueled 'rave' parties become dances of death for English youths

The union of the vegetable: the ritualised use of hoasca tea

In the Amazon rainforest there grow two plants: the mariri (Banisteriopsi caapi) and the chacrona (Psychotria viridis), which have been used by native Indians for hundreds of years to make an infusion. The infusion, known as ‘hoasca tea’, is no ordinary herbal brew but one with psychoactive properties. The leaves of these plants contain dimethyltryptamine (DMT), which has hallucinogenic effects, and beta-carbolines, which are monoamine oxidase inhibitors that prevent the degradation of DMT in the gastrointestinal tract. The preparation and consumption of these substances are legal in Brazil; although the Federal Council for Narcotics (CONFEN) states that they can only be used during recognised rituals.

Designer Drugs of Abuse

Designer drugs of abuse represent a major health risk to those who use them. The toxic effects of these agents are very dangerous when they are correctly identified, but they are especially dangerous because they are often misidentified by emergency room personnel. The three groups of designer drugs are the opiates, amphetamine derivatives and phencyclidine derivatives. Amphetamine derivatives such as MDMA and MDA can cause fatal sequelae including hyperthermia, hypertension, and seizures. No specific antidote exists for these agents. Therefore, their widespread use in certain areas is a major concern. The opiate derivatives M PPP, MPTP and the fentanyl analogues produce a wide range of toxic effects. These agents are much more potent than heroin, and are sometimes sold as heroin unknowingly to the user. The results have been catastrophic, with many fatalities. Arylhexylamines such as phencyclidine and ketamine are becoming more popular as agents of abuse. These drugs may result in fatal toxicity resulting from cardiac arrest, hypertensive emergency, or status epilepticus. Familiarity with the signs and symptoms of toxicity from the designer drugs will expedite the care of these patients.

REVIEW ■ : Long-lasting Effects of Recreational Drugs of Abuse on the Central Nervous System

Although a wealth of knowledge exists regarding the acute pharmacological effects of recreational drugs on the CNS, much less is known about the long-term toxic effects of recreational drugs on the CNS. Recent findings in nonhuman primates treated with amphetamine analogs, such as ±3,4-methylenedioxymetham phetamine (MDMA), indicate that these drugs can produce long-lasting, probably permanent, changes in brain serotonin innervation. Similarly, animals treated with phencyclidine (PCP) and related drugs develop neurodegenerative changes in selected brain regions. It seems clear, then, that some psychoactive drugs have the potential to produce persistent changes in CNS structure and, possibly, function. The goal of this article is to summarize current knowledge regarding the long-term effects of several popular recreational drugs, including MDMA and related amphetamine analogs, cocaine, marijuana, alcohol, PCP, lysergic acid (LSD), and opiates. Gaps in the current knowledge base are identified, and areas ripe for future research efforts are suggested. NEUROSCIENTIST 3:399-411, 1997

Drug-induced neurotoxicity in addiction medicine: From prevention to harm reduction

Neurotoxicity is considered as a major cause of neurodegenerative disorders. Most drugs of abuse have nonnegligible neurotoxic effects many of which are primarily mediated by several dopaminergic and glutamatergic neurotransmitter systems. Although many researchers have investigated the medical and cognitive consequences of drug abuse, the neurotoxicity induced by these drugs still requires comprehensive attention. The science of neurotoxicity promises to improve preventive and therapeutic strategies for brain disorders such as Alzheimer disease and Parkinson's disease. However, its clinical applications for addiction medicine remain to be defined adequately. This chapter reviews the most commonly discussed mechanisms underlying neurotoxicity induced by common drugs of abuse including amphetamines, cocaine, opiates, and alcohol. In addition, the known factors that trigger and/or predispose to drug-induced neurotoxicity are discussed. These factors include drug-related, individual-related, and environmental insults. Moreover, we introduce some of the potential pharmacological antineurotoxic interventions deduced from experimental animal studies. These interventions involve various targets such as dopaminergic system, mitochondria, cell death signaling, and NMDA receptors, among others. We conclude the chapter with a discussion of addicted patients who might benefit from such interventions.

Toxicity of amphetamines: an update

Amphetamines represent a class of psychotropic compounds, widely abused for their stimulant, euphoric, anorectic, and, in some cases, emphathogenic, entactogenic, and hallucinogenic properties. These compounds derive from the β-phenylethylamine core structure and are kinetically and dynamically characterized by easily crossing the blood-brain barrier, to resist brain biotransformation and to release monoamine neurotransmitters from nerve endings. Although amphetamines are widely acknowledged as synthetic drugs, of which amphetamine, methamphetamine, and 3,4-methylenedioxymethamphetamine (MDMA, ecstasy) are well-known examples, humans have used natural amphetamines for several millenniums, through the consumption of amphetamines produced in plants, namely cathinone (khat), obtained from the plant Catha edulis and ephedrine, obtained from various plants in the genus Ephedra. More recently, a wave of new amphetamines has emerged in the market, mainly constituted of cathinone derivatives, including mephedrone, methylone, methedrone, and buthylone, among others. Although intoxications by amphetamines continue to be common causes of emergency department and hospital admissions, it is frequent to find the sophism that amphetamine derivatives, namely those appearing more recently, are relatively safe. However, human intoxications by these drugs are increasingly being reported, with similar patterns compared to those previously seen with classical amphetamines. That is not surprising, considering the similar structures and mechanisms of action among the different amphetamines, conferring similar toxicokinetic and toxicological profiles to these compounds. The aim of the present review is to give an insight into the pharmacokinetics, general mechanisms of biological and toxicological actions, and the main target organs for the toxicity of amphetamines. Although there is still scarce knowledge from novel amphetamines to draw mechanistic insights, the long-studied classical amphetamines-amphetamine itself, as well as methamphetamine and MDMA, provide plenty of data that may be useful to predict toxicological outcome to improvident abusers and are for that reason the main focus of this review.

Review article: amphetamines and related drugs of abuse

Acute amphetamine toxicity is a relatively common clinical scenario facing the Australasian emergency medicine physician. Rates of use in Australasia are amongst the highest in the world. Clinical effects are a consequence of peripheral and central adrenergic stimulation producing a sympathomimetic toxidrome and a spectrum of central nervous system effects. Assessment aims to detect the myriad of possible complications related to acute amphetamine exposure and to institute interventions to limit associated morbidity and mortality. Meticulous supportive care aided by judicial use of benzodiazepines forms the cornerstone of management. Beta blockers are contraindicated in managing cardiovascular complications. Agitation and hyperthermia must be treated aggressively. Discharge of non-admitted patients from the emergency department should only occur once physiological parameters and mental state have returned to normal. All patients should receive education regarding the dangers of amphetamine use.

An exploration of recent club drug use among rave attendees

Raves are characterized by large numbers of youth dancing for long periods of time and by the use of "club drugs," such as 3, 4-methylenedioxymethamphetamine (MDMA or "ecstasy"). While a small body of research has explored the use of ecstasy and other club drugs (EOCD) among club rave attendees in the United States, we are aware of no studies that have investigated the relationship between EOCD use and high-risk sexual behaviors among members of this population. We explored the association between EOCD use and high-risk sexual behaviors among a sample of 283 club rave attendees interviewed during the spring and summer of 2005. Data were collected at 13 rave events in two different clubs along the Baltimore-Washington corridor between March 17 and September 3, 2005. Potential respondents were conveniently sampled and approached between 12 a.m. and 5 a.m. as they exited the clubs. Only 12% reported using ecstasy within the two days preceding the interview, findings considerably lower than our earlier studies of club rave attendees. Moreover, no significant relationship was discerned between recent MDMA use and high-risk sexual behavior. These findings suggest that the use of EOCD among rave attendees has diminished and that the allocation of significant resources to combat their proliferation, among this and other populations at risk for EOCD use, may be premature.

Music, substance use, and aggression

OBJECTIVE

This study investigated whether young people's substance use and aggressive behaviors are related to their listening to music containing messages of substance use and violence.

METHOD

Using self-administered questionnaires, data were collected from a sample of community-college students, ages 15-25 years (N=1056; 57% female). A structural equation model (maximum likelihood method) was used to simultaneously assess the associations between listening to various genres of music and students' alcohol use, illicit-drug use, and aggressive behaviors. Respondents' age, gender, race/ethnicity, and level of sensation seeking were included in the analyses as control variables.

RESULTS

Listening to rap music was significantly and positively associated with alcohol use, problematic alcohol use, illicit-drug use, and aggressive behaviors when all other variables were controlled. In addition, alcohol and illicit-drug use were positively associated with listening to musical genres of techno and reggae. Control variables (e.g., sensation seeking, age, gender and race/ethnicity) were significantly related to substance use and aggressive behaviors.

CONCLUSIONS

The findings suggest that young people's substance use and aggressive behaviors may be related to their frequent exposure to music containing references to substance use and violence. Music listening preference, conversely, may reflect some personal predispositions or lifestyle preferences. There is also the possibility that substance use, aggression, and music preference are independent constructs that share common "third factors".

Association of paradoxical sleep deprivation and ecstasy (MDMA) enhances genital reflexes in male rats

Ecstasy ((+/-)3,4-methylenedioxymethamphetamine, MDMA) is a psychostimulant and a synthetic derivative of amphetamine that, according to its consumers, promotes the enhancement of sexual pleasure. This study sought to investigate the effects of ecstasy in the genital reflexes of paradoxical sleep deprived (PSD) male rats. Distinct groups of PSD rats were administered with saline or different doses of ecstasy. The incidence of genital reflexes was verified for 100 min. The four doses that were used induced genital reflexes in PSD animals and these significantly differed from their respective treated control groups. Under the influence of two intermediary doses (2.5 and 5mg/kg), all animals displayed erection and ejaculation. The frequency of genital reflexes was also significantly greater than in relation to the PSD-saline group. The comparison between cocaine and ecstasy in PSD rats revealed that ecstasy induced more erections and ejaculations than cocaine. Thus, the present results showed a great enhancement of the genital reflexes of PSD rats that might have occurred due to serotoninergic alterations induced by this illicit substance when associated to sleep deprivation.

Portal surveys of time-out drinking locations: a tool for studying binge drinking and AOD use

Portal surveys, defined as assessments occurring proximal to the entry point to a high-risk locale and immediately on exit, can be used in different settings to measure characteristics and behavior of attendees at an event of interest. This methodology has been developed to assess alcohol and other drug (AOD) use at specific events and has included measuring intentions to use collected at entry and reported use on exit, as well as chemical tests for AOD consumption at both entrance and exit. Recent applications of the portal survey procedure to electronic music dance events that occur in established venues (e.g., bars or nightclubs) are discussed.

The pathophysiology of serotonin toxicity in animals and humans: implications for diagnosis and treatment

Serotonin toxicity (or serotonin syndrome) has become an increasingly common and important clinical problem in medicine over the last 15 years with the introduction of many new antidepressants that can cause increased levels of serotonin (5-HT) in the central nervous system (CNS). Severe and life-threatening cases are almost exclusively a result of combinations of antidepressants (usually monoamine oxidase inhibitors and selective serotonin reuptake inhibitors). Unfortunately, the term serotonin syndrome has a number of quite different meanings, and many people writing on this subject have failed to differentiate them. This has led to false conclusions regarding the 5-HT receptor subtypes responsible for the life-threatening effects in animal and human toxicity, and suggestions of ineffective treatment strategies. This review primarily addresses the serotonin receptor subtypes that underlie the clinical manifestations of excess CNS serotonin in humans and animals, and their implications for diagnosis and treatment. More specific diagnostic criteria for serotonin toxicity are required to identify situations when specific antidotes are likely to be useful. However, the mainstay of treatment of severe cases is good supportive care and early intubation and paralysis in life-threatening serotonin toxicity.

Simultaneous determination of amphetamines and ketamines in urine by gas chromatography/mass spectrometry

A method for the simultaneous determination of amphetamines and ketamines (ketamine, norketamine and dehydronorketamine) in urine samples by gas chromatography/mass spectrometry was developed and validated. Urine samples were extracted with organic solvent and derivatized with trifluoroacetic anhydride (TFAA). The limits of detection and limits of quantification for each analyte were lower than 19 and 30 ng/mL, respectively. Within-day and between-day precisions were within 0.5% and 10.6%, respectively. Biases for three levels of control samples were within -10.6% and +7.8%. The concentration of dehydronorketamine was greater than those of ketamine or norketamine in 19 of 35 ketamine-positive samples. A group of 110 human urine samples previously determined to contain at least one of the target analytes was analyzed using the new method, and excellent agreement was observed with previous results.

Underground pill testing, down under

At a recent South Australian rave, results reported to users from on-site pill-testing, using pill-testing kits, were compared with GCMS analysis of a scraping from the same pill. The presence of an ecstasy-like substance or methylamphetamine was correctly reported to users in 100% of pills that contained those substances. However only 11% of pills with combinations of illicit substances had both substances correctly identified. Ketamine was particularly problematic with identification occurring in only 18% of pills and in some instances, the colorimetric response obtained from ketamine was confused with the response from methylamphetamine. This study also allowed a comparison between pill design and composition encountered at the rave with those submitted to the forensic laboratory over a 6-month period including the month the rave was held. MDMA was present in 68% of pills at the rave and 89% of pills submitted by the police. Ketamine was present in 27 and 26% of pills, respectively and was often combined with other substances. The combinations of illicit substances were identical apart from one police-pill seizure that contained MDMA combined with PMA. This combination has not been previously encountered in South Australia. The pill designs observed at the rave differed significantly from the designs on pills submitted for testing by police. These differences limit the use of pill comparison charts as an alternative identification tool to colorimetric pill testing in South Australia.

Absorption and clearance of ±3,4-methylenedioxymethamphetamine from the plasma of neonatal rats

A limited number of studies exist describing the effects of +/-3,4-methylenedioxymethamphetamine (MDMA) during perinatal development, although the number of MDMA users has increased dramatically, and this increase is greatest in people of child-bearing age. Previous experimental studies show that exposure to MDMA during part of the third trimester-equivalent (postnatal days P1-20 in rats) cause two distinct types of learning and memory deficits (sequential and spatial) if exposed on P11-20, but not if exposure occurs on P1-10. In the present study, we examined differences in the ability of neonatal rats to eliminate MDMA. Rat offspring were given a single dose of 20 mg/kg MDMA on either P1 or 11, and plasma was collected at 1 of 10 time points during a 10-h period. MDMA concentrations were assessed by liquid chromatography/mass spectrometry (LC/MS). Indices of absorption did not differ as a function of exposure age. Exposure age differences in the clearance rate and half-life of MDMA were observed, such that the P1-treated animals had a significantly more rapid clearance and a shorter half-life than P11-treated animals did. These changes are in the same direction as the behavioral differences reported previously between P1-10 and P11-20 MDMA exposure groups. However, the pharmacokinetic differences were not commensurate with the behavioral changes in that the clearance differences at the two ages are quantitative whereas the behavioral differences were qualitative (no effects from P1-10 exposure and large effects from P11-20). Although the data do not suggest a mechanism for the learning deficits, they indicate that pharmacokinetic differences may contribute to the effects seen when exposure is begun on P11.

Interpretation of a 3,4-methylenedioxymethamphetamine (MDMA) blood level: discussion by means of a distribution study in two fatalities

The amphetamine derivative 3,4-methylenedioxymethamphetamine (MDMA, "Ecstasy" is a currently used or abused designer drug and fatalities are frequently encountered in forensic practice. However, the question remains open whether an MDMA blood level can be toxic or even potentially lethal. In order to provide insight in the interpretation of a detected MDMA concentration, the distribution of MDMA and its metabolite 3,4-methylenedioxyamphetamine (MDA) in various body fluids and tissues was studied and discussed in two different fatalities. Apart from peripheral blood samples (such as femoral and subclavian blood), various blood samples obtained centrally in the human body and several body fluids (such as vitreous humour) were examined. In addition, various tissues such as cardiac muscle, lungs, liver, kidneys, and brain lobes were analysed. In contrast to the peripheral blood levels, high MDMA and MDA levels were found in cardiac blood and the majority of the organs, except for the abdominal adipose tissue. The high concentrations observed in all lung lobes, the liver and stomach contents indicate that post-mortem redistribution of MDMA and MDA into cardiac blood can occur and, as a result, blood sampled centrally in the body should be avoided. Therefore, our data confirm that peripheral blood sampling remains "the golden standard". In addition, a distinct difference in peripheral blood MDMA concentrations in our two overdose cases was established (namely 0.271 and 13.508 microg/ml, respectively). Furthermore, our results suggest that, if a peripheral blood sample is not available and when putrefaction is not too pronounced, vitreous humour and iliopsoas muscle can be valuable specimens for toxicological analysis. Finally, referring to the various mechanisms of death following amphetamine intake, which can result in different survival times (e.g. cardiopulmonary complications versus hyperthermia), the anatomo-pathological findings and the toxicological results should be considered as a whole in arriving at a conclusion.

Ecstasy intoxication: the toxicological basis for treatment

Youngsters are increasingly using 3,4 methylenedioxymethamphetamine, known as ecstasy, because it is wrongly believed that it does not induce harm. However, there are many reports of adverse effects, including acute intoxication, abuse potential, and possible neurotoxic effects. Therefore, health care providers need to promptly recognize the symptoms of systemic intoxication in order to initiate early treatment. The drug is used by the oral route for long hours during crowded dance parties. Acutely, ecstasy increases the release of serotonin and decreases its reuptake, leading to hypertension, hyperthermia, trismus, and vomiting. There is debate on whether recreational doses of ecstasy cause permanent damage to human serotonergic neurons. Ecstasy users showed a high risk of developing psychopathological disturbances. The prolonged use of ecstasy might induce dependence, characterized by tolerance and hangover. Acute ecstasy intoxication needs emergency-type treatment to avoid the dose-dependent increase in adverse reactions and in severity of complications. There are no specific antidotes to be used during acute intoxication. Supportive measures and medical treatment for each one of the complications should be implemented, keeping in mind that symptoms originate mainly from the central nervous system and the cardiovascular system.

Toward an ecstasy and other club drug (EOCD) prevention intervention for rave attendees

A growing body of recent research has identified that "rave" attendees are at high risk for the use of "club drugs," such as 3,4-methylenedioxymethamphetamine (MDMA or "ecstasy"). Rave attendees, however, comprise only one of several club-going populations. In the current study, we explore the prevalence of ecstasy and other club drug (EOCD) use among a sample of club attendees in Washington, DC. Data were collected from adult, primarily homosexual, club attendees during the summer of 2003. Data collection was scheduled between 11 p.m. and 3 a.m. Participation rates were high. Of the 211 club attendees approached, 88% (n = 186) completed the interview. Drug use prevalence rates were low. With the exception of alcohol and marijuana, 2-day self-reports were less than 1% for each drug. These findings, amalgamated with results from other EOCD-related studies involving several distinct populations, offer considerable insight into the state of ecstasy in American society. Based on a meta-analysis of this literature, we offer a community-level prevention intervention for the population at highest risk for EOCD use-rave attendees.

Profiles of urine samples from participants at rave party in Taiwan: prevalence of ketamine and MDMA abuse

Drug abuse patterns are different due to cultural, social and geographical differences. Methamphetamine (MA) is the most important drug of abuse in Taiwan followed by opiates. Recently, there has been an increase of ketamine and MDMA abuse in disco dancing clubs. Here, we report the patterns of drug abuse by the participants in a metropolitan city disco-dancing club and the general public in Taiwan. The positive rates of common drugs of abuse detected in samples collected from participants in a dancing club were as follows: MDMA, 75.7%; ketamine, 47.0%; MA, 41.6%; opiates, 0%. Marijuana and cocaine were detected at much lower rates (3.4 and 4.7%, respectively). Ketamine and one of the amphetamines were detected together in 42.9% of the samples. The positive rates in samples collected from police detainees suspected of drug abuse in the general public were as follows: MA, 76.0%; OPA, 37.0%; MDMA, 6.0%; ketamine, 2.0%.

Illicit drug-related harm during the Sydney 2000 Olympic Games: implications for public health surveillance and action

AIMS

To describe presentations to emergency departments during the Sydney 2000 Olympic Games for conditions related to the use of illicit drugs; to discuss the implications of such presentations for surveillance and public health action at similar events in the future.

DESIGN

Identification of target presentations in sentinel emergency departments; entry of data into a purpose-built database; and daily electronic transfer of data for central collation and analysis.

SETTING

Fifteen sentinel emergency departments in the greater Sydney metropolitan area for a 38-day period spanning the Sydney 2000 Olympic Games.

PARTICIPANTS

Four hundred and twenty-four presentations to sentinel emergency departments with conditions related to illicit drug use.

MEASUREMENTS

Patient's age, sex, country and region of residence, location of emergency department, types of illicit drugs involved and departure status.

FINDINGS

The mean daily number of presentations for adverse events due to illicit drug use was significantly higher (13.3 versus 8.8 presentations, t = 2.2, P = 0.04) in the 2-week Olympic Games period than in the lead-up to the Games, culminating in a large peak following the closing ceremony. There was also a significant increase (5.1 versus 1.7 presentations, t = 2.8, P = 0.007) in the mean daily number of presentations related to use of ecstasy or amphetamines, whereas no change was noted in presentations related to heroin use. Over half (52%) of presentations occurred at two emergency departments in areas known as being 'hot-spots' for illicit drug use.

CONCLUSIONS

Enhanced surveillance of adverse events following illicit drug use, possibly targeting known 'hot-spots', should be considered for future mass events. Advance preparation of preventive strategies, such as 'party-safe' messages, will enable rapid response to unusual patterns of illicit drug-related harm during future mass events.

Preprotachykinin A gene expression after administration of 3,4-methylene dioxymethamphetamine (Ecstasy)

This study tested the effects of 8 days of subchronic administration of 3,4-methylene dioxymethamphetamine (MDMA) (5 mg/kg b.w.) on preprotachykinin A mRNA levels in discrete rat brain regions. In situ hybridization examined preprotachykinin A mRNA levels in the core and shell of the nucleus accumbens, the islands of Calleja, the olfactory tubercle, the dorsal and ventral caudate-putamen, the bed nucleus of the stria terminalis, the medial preoptic area, the medial habenular nucleus and in the postero-dorsal part of the medial amygdala. Higher levels of preprotachykinin A mRNA were found in the core and shell of the nucleus accumbens, in the islands of calleja, in the olfactory tubercle, in the bed nucleus of the stria terminalis, in the medial habenular nucleus and the postero-dorsal part of the medial amygdala, compared to control animals. Conversely, increased preprotachykinin A mRNA levels were observed in the dorsal and ventral caudate-putamen in MDMA treated when compared to control rats. In the social memory test, MDMA significantly impaired rats' short-term working memory. These results show that chronic exposure to MDMA strongly affects preprotachykinin A mRNA levels in discrete rat brain regions. These changes occur in experimental conditions in which working memory is markedly reduced, suggesting that changes in gene expression of tachykinin mechanisms may contribute to the effects of MDMA on memory function.

Estimating the prevalence of Ecstasy use among juvenile offenders

To date, no studies have examined Ecstasy use among criminal justice populations. Focusing on individuals under criminal justice supervision is useful because "new" illegal drugs will typically take root in a criminal population before diffusing to the general population. In the current study, self-report drug use data and urine specimens were collected from 209 juvenile offenders surveyed through Maryland's Offender Population Urinalysis Screening (OPUS) Program. Prevalence estimates are generated and associations between Ecstasy use, demographic characteristics, and alcohol and other drug use are explored. Sixteen percent of the sample reported using Ecstasy within the past 12 months, an estimate almost three times as high as grade school and high school students surveyed through the Monitoring the Future survey. Compared to nonusers. Ecstasy users were significantly more likely to be female (45% versus 20%, p < 0.01), White (82% versus 22%, p < 0.001), and out of school (39% versus 20%, p < 0.05). Associations were also found between Ecstasy use and the use of other drugs. These findings suggest that the recent use of Ecstasy among juvenile offenders is higher than estimated use in the general student population, and that youthful offenders may represent an important population for potential intervention.

Stability study of the designer drugs "MDA, MDMA and MDEA" in water, serum, whole blood, and urine under various storage temperatures

A controlled study was undertaken to determine the stability of the designer drugs MDA, MDMA and MDEA in pooled serum, whole blood, water and urine samples over a period of 21 weeks. The concentrations of the individual designer drugs in the various matrices were monitored over time, in the dark at various temperatures (-20, 4 or 20 degrees C), for a low (+/- 6 ng/ml for water, serum and whole blood and +/- 150 ng/ml for urine) and a high concentration level (+/- 550 ng/ml for water, serum and whole blood and +/- 2500 ng/ml for urine). Compound concentrations were measured using a validated HPLC assay with fluorescence detection. Our study demonstrated no significant loss of the designer drugs in water and urine at any of the investigated temperatures for 21 weeks. The same results were observed in serum for up to 17 weeks, and up to 5 weeks in whole blood. After that time, the compounds could no longer be analyzed due to matrix degradation, especially in the low concentration samples that were stored at room temperature. This study demonstrates that the designer drugs, MDA, MDMA and MDEA are stable when stored at -20 degrees C for 21 weeks, even in haemolysed whole blood.

MDMA and fenfluramine alter the response of the circadian clock to a serotonin agonist in vitro

The substituted amphetamine drugs, 3,4-methylenedioxymethamphetamine (MDMA or 'Ecstasy') and fenfluramine, are known to damage 5-HT neurons in the brain of animals. However, little is known about the drugs' effects on circadian rhythmicity which is known to be influenced by serotonergic input to the suprachiasmatic nuclei. In the present study, we tested the ability of MDMA and fenfluramine treatment to alter the ability of the circadian clock to reset in response to an agonist of the 5-HT1A and 5-HT7 receptor subtypes soon after treatment with the drugs, and then again at 20 weeks. Coronal hypothalamic slices containing the suprachiasmatic nuclei (SCN) were prepared from rats and 3-min recordings of the firing rate of individual cells were performed throughout a 12-h period. The ability of the 5-HT agonist, 8-hydroxy-2-(dipropylamino)tetralin (8-OH-DPAT), to cause a phase advance in the firing pattern of SCN neurons was assessed in slices from control animals and those pretreated with MDMA or fenfluramine (10, 15 and 20 mg/kg administered on successive days) 6-10 days or 20 weeks previously. Phase advances to 8-OH-DPAT in the slice were attenuated by pretreatment with MDMA or fenfluramine at both drug-test intervals. Our study demonstrates that repeated exposure to MDMA or fenfluramine may interfere with the ability of serotonin to phase shift the circadian clock in the rat. It is possible that such an effect may be responsible for some of the clinical changes, such as sleep disorders and mood changes, sometimes reported by human users of the substituted amphetamines.

3,4-methylenedioxymethamphetamine (ecstasy)-induced learning and memory impairments depend on the age of exposure during early development

Use of 3,4-methylenedioxymethamphetamine (MDMA; ecstasy) has increased dramatically in recent years, yet little is known about its effects on the developing brain. Neonatal rats were administered MDMA on days 1-10 or 11-20 (analogous to early and late human third trimester brain development). MDMA exposure had no effect on survival but did affect body weight gain during treatment. After treatment, body weight largely recovered to 90-95% of controls. MDMA exposure on days 11-20 resulted in dose-related impairments of sequential learning and spatial learning and memory, whereas neonatal rats exposed on days 1-10 showed almost no effects. At neither stage of exposure did MDMA-treated offspring show effects on swimming ability or cued learning. Brain region-specific dopamine, serotonin, and norepinephrine changes were small and were not correlated to learning changes. These findings suggest that MDMA may pose a previously unrecognized risk to the developing brain by inducing long-term deleterious effects on learning and memory.

Ecstasy is a dangerous drug

Ecstasy, a dangerous psychoactive drug, has become a popular recreational drug on college campuses and dance halls in the United States, United Kingdom, and around the world. No reports on ecstasy have shown addictiveness, and some users of ecstasy claim they prefer infrequent use which is not the usual addictive pattern. Jaw clenching, bruxism, and some cardiac arrhythmias requiring medical attention have been associated with consumption of ecstasy and some fatalities. In large scale retrospective questionnaire studies of subjective experiences users claimed that they felt a gentle relaxation and openness to others and few adversive effects. In rats and monkeys ecstasy has caused depletion of the neurotransmitter serotonin in the brain but similar effects have not been identified for humans. Case reports have shown panic attacks, flashbacks, paranoia, and even fatalities. The Drug Enforcement Administration in 1985 placed ecstasy in Schedule I, the most restrictive drug category.

Survey of patient satisfaction in adult psychiatric outpatient clinics

A client satisfaction survey was undertaken in two adult psychiatric outpatient clinics. The anonymous self-report questionnaire covering demographic, setting and satisfaction with service variables was endorsed by 203 participants. The mean age of the subjects was 42.5 +/- 19 years, with a small majority (58.6%) of females. Overall satisfaction with psychiatric care was high (79.8%). None of the demographic or setting variables correlated significantly with satisfaction. Psychoeducation was significantly correlated with level of satisfaction with services. These findings further emphasize the importance of psychoeducation by service providers in mental health.

Psychobiological risk factors for vulnerability to psychostimulants in human adolescents and animal models

Adolescence is associated with an increased risk of developing drug abuse/dependence. During this ontogenetic phase, brain and hormonal systems are still undergoing crucial maturational rearrangements, which take place together with significant modifications in psychosocial development. However, the neurohormonal and behavioral facets of adolescence have been poorly investigated in relation to the vulnerability to psychostimulants such as MDMA ("Ecstasy") and amphetamine (AMPH). Novelty-seeking, a temperamental/behavioral trait that is typical of this age period, might substantially contribute to both psychological and psychobiological vulnerability. In humans, an elevated score of novelty-sensation seeking and a derangement of monoaminergic function were both associated with late adolescence MDMA users compared to controls. In animal models of periadolescence, the search for novel stimuli and sensations actually shares a common neurobiological substrate (the reward-related brain mesolimbic pathways) with psychostimulants. The present review summarises recent work in mice, which indicates that periadolescent subjects are characterized by an unbalanced and "extremes-oriented" behavior and by elevated novelty-seeking compared to adults. Repeated and intermittent administration of cocaine or AMPH was associated with the development of a prominent locomotor sensitization in periadolescents, which failed to exhibit the marked sensitization of the stereotyped behavioral syndrome--possibly associated with poor welfare--that was typical of adults. A unique profile of integrated behavioral and physiological hyporesponsivity to both forced novelty and acute AMPH administration during periadolescence was also found. As a whole, these results, together with previous work on this topic, suggest that periadolescents may be more "protected" from AMPH-related aversive properties, and perhaps more vulnerable to the experience of internal states of reward, than older animals. Thus, the present animal model of adolescence seems to represent a reliable and useful method for the investigation of vulnerability to a variety of habit-forming agents or emotional experiences whose positive reinforcing properties may rely on common neurobiological substrates. A deeper understanding of psychostimulant effects during adolescence on the complex interaction between genetic, neurobiologic, psychosocial, and environmental factors will lead to earlier and more effective prevention and treatment.

3,4-Methylenedioxymethamphetamine (ecstasy)-induced hepatotoxicity: effect on cytosolic calcium signals in isolated hepatocytes

AIMS/BACKGROUND

Hepatocellular damage has been reported as a consequence of 3,4-methylenedioxymethamphetamine (MDMA) intake. However, little is known about the cellular mechanisms involved. The present study was undertaken to evaluate the effects of MDMA on cell viability as well as free calcium levels ([Ca2+]i) in short-term cultured hepatocytes. Reduced glutathione (GSH), adenosine-5'-triphosphate (ATP) and lipid peroxidation were investigated to evaluate the toxic effect of MDMA, in vitro, using freshly isolated rat hepatocytes.

METHODS

In order to measure cytosolic free Ca2+ concentrations ([Ca2+]i), rat hepatocytes were loaded with the Ca2+ indicator fura-2-acetoxymethylester (fura-2-AM).

RESULTS

A sustained rise of ([Ca2+]i) after incubation with MDMA was the most noteworthy finding. In Ca2+-free medium, MDMA caused a reduced increase of ([Ca2+]i). On the other hand, MDMA (0.1-5 mM) induced a concentration-dependent and time exposure-dependent GSH and ATP depletion. Although it did not reach statistical significance, GSH deficits were accompanied by a tendency to increase lipid peroxidation 3 h after MDMA incubation.

CONCLUSIONS

The above data suggest that the marked rise of ([Ca2+]i) and subsequent ATP and GSH depletion can lead to a rapid decrease in cell viability.

Fatal multi-organ failure after suicidal overdose with MDMA, 'ecstasy': case report and review of the literature

A 53-year-old prisoner died of multiorgan failure after a suicidal overdose with 3,4-methylenedeoxymethamphetamine (MDMA, 'Ecstasy'). Twelve hours after ingestion of MDMA, the patient became severely hyperthermic (107.2 degrees F) with evidence of rhabdomyolysis. He subsequently developed acute respiratory distress syndrome (ARDS), disseminated intravascular coagulopathy (DIC) and acute renal failure. At autopsy, plasma concentration of MDMA was 3.05 mg/L. This case shows that MDMA is still abused in our community and clinicians should know the symptoms of MDMA intoxication. In particular, MDMA should be considered when patients have symptoms or signs of increased sympathetic activity. The pathophysiology and treatment of MDMA-induced hyperthermia are discussed.

Survival after massive ecstasy overdose

INTRODUCTION

The toxicity profile of the amphetamine derivative 3,4-methylenedioxymethamphetamine (MDMA, "Ecstasy") is well known. This designer drug is usually taken at "house parties" and may cause severe complications, sometimes leading to death, even when taken in relatively small units (1 or 2 tablets). Up to now, only a few cases of survival after ingestion of an overdose of Ecstasy have been described. In most cases the users developed hyperthermia, disseminated intravascular coagulation, rhabdomyolysis, and renal failure.

CASE REPORT

We describe a man who, after ingesting 50 tablets of Ecstasy (in combination with oxazepam and alcohol) at home, recovered within 2 days. Presenting features were unconsciousness, apnea, and convulsions. It is suggested that in most cases severe 3,4-methylenedioxymethamphetamine toxicity results from an interaction between direct pharmacological effects of the drug and the prevailing environmental conditions (high ambient temperature, dancing in trance, little fluid intake).

[Ecstasy: a pharmacological review]

A literature review on 3,4 methylenedioxymethanphetaneine (MDMA), known as ecstasy, a drug with increased use among youngsters is presented. The history from its synthesis, up to its use as an adjunct to psychotherapy and, more recently, as a drug of abuse, is described. The possible pattern of abuse in several countries is reviewed with the objective of predicting what might happen in Brazil, where some reports of abuse have already appeared. The pharmacokinetics of MDMA is also reviewed to explain the consequences for pharmacological activity, toxicology and adverse effects. The clinical outcome of both short and middle-term intoxication is summarized and the clinical symptoms of severe intoxication with ecstasy, are described. The studies undertaken on its mechanism of action are detailed to explain its toxic psychiatric and physical side effects, to explain the mechanism of self-administration of the drug and to propose a therapeutic possibility of treating intoxication.

Intentional overdose and death with 3,4-methylenedioxyethamphetamine (MDEA; "Eve"): case report

We report a case of suicide following ingestion of a large dose of 3,4-methylenedioxyethamphetamine (MDEA, "Eve") in a 27-year-old woman with a history of depression. Several days before her death, she had attempted suicide with benzodiazepines resulting in a 24-hour hospital admission; at that time, no physiologic abnormalities were detected. Findings on autopsy were nonspecific. Toxicologic analysis showed a high concentration of MDEA and the appearance of benzodiazepines in body fluids. Ethanol and other drugs of abuse were not found. We discuss the clinical manifestations, toxicologic syndromes, and mechanisms of death with amphetamine intoxication. MDEA intoxication in young people may result in sudden death.

Myoglobinuria, malignant hyperthermia, neuroleptic malignant syndrome and serotonin syndrome

This article presents an overview of the causes and manifestations of myoglobinuria and provides criteria for its diagnosis and management. The article also reviews neuroleptic malignant syndrome, malignant hyperthermia, and serotonin syndrome, all of which could cause rhabdomyolysis and myoglobinuria.

Induction of Fos protein by 3,4- methylenedioxymethamphetamine (Ecstasy) in rat brain: regional differences in pharmacological manipulation

Psychostimulant drugs have been reported to increase the expression of some immediate-early genes in the brain. In the present study, immunohistochemical techniques were used to assess the pattern of Fos protein produced by 3,4-methylenedioxymethamphetamine (MDMA) in several brain regions. Furthermore, we also studied the role of the dopamine D and D receptors and the N-methyl- D-aspartate (NMDA) receptor in the induction of Fos protein by MDMA. A single administration of MDMA (5, 10 or 20 mg/kg) caused marked induction of Fos-immunoreactivity in several regions including frontal cortex, striatum and olfactory tubercle of rat brain, in a dose-dependent manner. However, in the hippocampus and cerebellum, there were few or no Fos immunoreactive cells induced by MDMA. Furthermore, the induction of Fos protein in the striatum and olfactory tubercle after administration of MDMA (10 mg/kg) was blocked by pre-treatment with the dopamine D receptor antagonist SCH 23390 (1 mg/kg) or the NMDA receptor antagonist dizocilpine (1 mg/kg), but not by the dopamine D receptor antagonist (-)-sulpiride (100 mg/kg). However, the induction of Fos protein in the frontal cortex and hippocampus by MDMA was unaltered by pretreatment with SCH 23390 (1 mg/kg) or (-)-sulpiride (100 mg/kg). These results suggest that MDMA induces the expression of Fos protein in several regions of rat brain, and that the expression of Fos protein by MDMA in the striatum and olfactory tubercle appears to be mediated at least in part by the dopamine D and NMDA receptors.

Selective serotonin reuptake inhibitor-induced serotonin syndrome: review

The selective pharmacology of the selective serotonin reuptake inhibitors (SSRIs) results in a lower potential for pharmacodynamic drug interactions relative to other antidepressants such as the tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs). However, the SSRIs have been implicated in the development of the serotonin syndrome--a potentially life-threatening complication of treatment with psychotropic drugs. The syndrome is produced most often by the concurrent use of two or more drugs that enhance central nervous system serotonin activity and often goes unrecognized because of the varied and nonspecific nature of its clinical features. The serotonin syndrome is characterized by alterations in cognition (disorientation, confusion), behavior (agitation, restlessness), autonomic nervous system function (fever, shivering, diaphoresis, diarrhea), and neuromuscular (ataxia, hyperreflexia, myoclonus) activity. The difference between this syndrome and the occurrence of adverse effects caused by serotonin reuptake inhibitors alone is the clustering of the signs and symptoms, their severity, and their duration. There are important pharmacokinetic interactions between SSRIs and other serotonergic drugs due principally to their effects on the cytochrome P450(CYP) isoenzymes, the potential for which varies widely amongst the SSRI group, which may increase the likelihood of a pharmacodynamic interaction. The exceptionally long washout period required after fluoxetine discontinuation may cause additional problems and/or inconvenience. Patients with serotonin syndrome usually respond to discontinuation of drug therapy and supportive care alone, but they may also require treatment with antiserotonergic agent such as cyproheptadine, methysergide, and/or propranolol. To reduce the occurrence, morbidity, and mortality of the serotonin syndrome, it must be both prevented by prudent pharmacotherapy and given prompt recognition when it is present.

2,5-Bis-(glutathion-S-yl)-alpha-methyldopamine, a putative metabolite of (+/-)-3,4-methylenedioxyamphetamine, decreases brain serotonin concentrations

3,4-(+/-)-Methylenedioxyamphetamine (MDA) and 3,4-(+/-)-methylenedioxymethamphetamine (MDMA) are serotonergic neurotoxicants. However, when injected directly into brain, MDA and MDMA are not neurotoxic, suggesting that systemic metabolism plays an important role in the development of neurotoxicity. The nature of the metabolite(s) responsible for MDA- and MDMA-mediated neurotoxicity is unclear. alpha-Methyldopamine is a major metabolite of MDA and is readily oxidized to the o-quinone, followed by conjugation with glutathione (GSH). Because the conjugation of quinones with GSH frequently results in preservation or enhancement of biological (re)activity, we have been investigating the role of quinone-thioethers in the acute and long-term neurochemical changes observed after administration of MDA. Although intracerebroventricular (i.c.v.) administration of 5-(glutathion-S-yl)-alpha-methyldopamine (4 x 720 nmol) and 5-(N-acetylcystein-S-yl)-alpha-methyldopamine (1 x 7 nmol) to Sprague-Dawley rats produced overt behavioral changes similar to those seen following administration of MDA (93 mumol/kg, s.c.) they did not produce long-term decreases in brain serotonin (5-hydroxytryptamine, 5-HT) concentrations. In contrast, 2,5-bis-(glutathion-S-yl)-alpha-methyldopamine (4 x 475 nmol) decreased 5-HT levels by 24%, 65% and 30% in the striatum, hippocampus and cortex, respectively, 7 days after injection. The relative sensitivity of the striatum, hippocampus and cortex to 2,5-bis-(glutathion-S-yl)-alpha-methyldopamine was the same as that observed for MDA; the absolute effects were greater with MDA. The effects of 2,5-bis-(glutathion-S-yl)-alpha-methyldopamine were also selective for serotonergic nerve terminal fields, in that 5-HT levels were unaffected in regions of the cell bodies. Because 2,5-bis-(glutathion-S-yl)-alpha-methyldopamine caused long-term depletion in 5-HT without adversely affecting the dopaminergic system, it also mimics the selectivity of MDA/MDMA. The data imply a possible role for quinone-thioethers in the neurobehavioral and neurotoxicological effects of MDA/MDMA.

Determination of amphetamine and methylenedioxy-amphetamine-derivatives in hair

Two GC/MS-procedures for the detection of amphetamine and its methylenedioxy-derivatives (MDA, MDMA and MDE) in hair are presented. In these methods a methanol sonication extraction technique was applied. The extracted drugs were derivatized either with propionic acid anhydride (PSA) or trifluoroacetic acid anhydride (TFA). PSA-derivatives are more stable than TFA-derivatives, but the latter provide more specific mass-spectrometric information, and, therefore, seem to be preferably for amphetamine determination. The detection limit for all compounds was in a range of about 0.01 ng/mg, if at least 50-100 mg of hair were analyzed, independent of the derivatization used.

[Serotonin syndrome: critical review of the literature]

Since Sternbach's first review, serotonin syndrome has been reported many times. Our purpose was to examine this concept's pertinence, utility and meaning. Its physiopathology remains unclear: 5-HT1A receptors activation is certain, but others mechanisms and individual or family factors could be also involved. Appearance circumstances are more various than first expected. The concept of serotonin syndrome seems to bring together entities that differ in physiopathology and seriousness, and we propose to distinguish between serotonin syndrome and other types of syndromes. Knowing serotonin syndrome is useful both for prevention and for recognizing it as a potentially lethal emergency.

Chronic ecstasy (3,4-methylenedioxymetamphetamine) abuse: a recurrent and unpredictable cause of severe acute hepatitis

Fifteen reports of hepatitis induced by ecstasy (MDMA, 3,4-methylenedioxymetamphetamine) have been published over the last 3 years. With the increasing enthusiasm for "Rave" parties, the incidence appears to be increasing, and is an important and often concealed cause of acute hepatitis in young people. We report two cases of recurrent ecstasy-associated hepatitis where the interval between drug consumption and jaundice was variable and the link therefore initially obscured. Liver biopsies of both patients showed acute hepatitis. One was of relatively mild degree, and the other was severe, with features suggesting auto-immune hepatitis. Both cases resolved spontaneously. A high index of suspicion and careful specific enquiry are necessary to make the diagnosis and warn the patient to abstain in future, since subsequent attacks may be fatal and insidious chronic damage may occur.