1
|
Gautam S, Neupane A, Molina IDLH, Villarreal JB, Li W, Mahmud TAH. MDMA("Ecstasy") abuse leading to delayed onset rhabdomyolysis: A case report and literature review. Clin Case Rep 2024; 12:e9429. [PMID: 39253371 PMCID: PMC11381184 DOI: 10.1002/ccr3.9429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Revised: 08/29/2024] [Accepted: 08/31/2024] [Indexed: 09/11/2024] Open
Abstract
MDMA and cocaine can result in acute onset rhabdomyolysis. However, delayed onset rhabdomyolysis and its pathophysiology is of concern Early therapeutic intervention improves prognosis. Such cases should be promptly referred and managed in centers equipped with critical care and renal replacement therapy.
Collapse
Affiliation(s)
| | | | | | | | - Weiying Li
- Internal Medicine Advent Health Orlando Florida USA
| | | |
Collapse
|
2
|
Freidel N, Kreuder L, Rabinovitch BS, Chen FY, Huang RST, Lewis EC. Psychedelics, epilepsy, and seizures: a review. Front Pharmacol 2024; 14:1326815. [PMID: 38283836 PMCID: PMC10811552 DOI: 10.3389/fphar.2023.1326815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 12/07/2023] [Indexed: 01/30/2024] Open
Abstract
Psychedelic compounds have been utilized by humans for centuries for medicinal, religious, and tribal purposes. Clinical trial data starting from the early 2000s and continuing today indicates that psychedelics are a clinically efficacious treatment for a variety of neurological and psychiatric disorders. However, all clinical trials examining these substances have excluded any individual with a past or current history of seizures, leaving a large cohort of epilepsy and non-epilepsy chronic seizure disorder patients without anywhere to turn for psychedelic-assisted therapy. These exclusions were made despite any significant evidence that clinically supervised psychedelic use causes or exacerbates seizures in this population. To date, no clinical trial or preclinical seizure model has demonstrated that psychedelics induce seizures. This review highlights several cases of individuals experiencing seizures or seizure remission following psychedelic use, with the overall trend being that psychedelics are safe for use in a controlled, supervised clinical setting. We also suggest future research directions for this field.
Collapse
Affiliation(s)
- Ninon Freidel
- Department of Clinical Research, Numinus Toronto, Toronto, ON, Canada
- Department of Neuroscience, University of British Columbia Djavad Mowafaghian Centre for Brain Health, Vancouver, BC, Canada
| | - Liliane Kreuder
- Department of Clinical Research, Numinus Toronto, Toronto, ON, Canada
- Department of Medical Biophysics, University of Toronto Temerty Faculty of Medicine, Toronto, ON, Canada
| | - Brenden Samuel Rabinovitch
- Department of Clinical Research, Numinus Toronto, Toronto, ON, Canada
- Krembil Research Institute, University Health Network, Toronto, ON, Canada
- Department of Physiology, University of Toronto Temerty Faculty of Medicine, Toronto, ON, Canada
| | - Frank Yizhao Chen
- Department of Clinical Research, Numinus Toronto, Toronto, ON, Canada
- Department of Research, Jamaican Medical Cannabis Corporation, Toronto, ON, Canada
| | - Ryan S. T. Huang
- Department of Clinical Research, Numinus Toronto, Toronto, ON, Canada
- Department of Medicine, University of Toronto Temerty Faculty of Medicine, Toronto, ON, Canada
| | - Evan Cole Lewis
- Department of Clinical Research, Numinus Toronto, Toronto, ON, Canada
- Department of Pediatrics, University of Toronto Temerty Faculty of Medicine, Toronto, ON, Canada
| |
Collapse
|
3
|
Ghaffari-Rafi A, Eum KS, Villanueva J, Jahanmir J. Protracted hyperthermia and delayed rhabdomyolysis in ecstasy toxicity: A case report. Medicine (Baltimore) 2020; 99:e21842. [PMID: 33031256 PMCID: PMC7544301 DOI: 10.1097/md.0000000000021842] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
RATIONALE Despite toxicity and unpredictable adverse effects, ecstasy use has increased in the United States. Onset of hyperpyrexia, rhabdomyolysis, disseminated intravascular coagulation (DIC), among other symptoms, occurs within hours of ingestion. Moreover, patients who experience hyperpyrexia, altered mental status, DIC, and multiorgan failure, rarely survive. This case presents a chronic ecstasy user whose symptoms would have predicted mortality. The report demonstrates a patient who experiences protracted hyperthermia, with delayed rhabdomyolysis and DIC. In addition, his peak creatine kinase (CK) of 409,440 U/L was far greater than the expected 30,000 to 100,000 U/L, being the second largest CK recorded in a survivor. PATIENT CONCERNS This case report presents a 20-year-old man who presented to the emergency department after experiencing a severe reaction to ecstasy. He was a chronic user who took his baseline dosage while performing at a music event. He experienced hyperpyrexia immediately (106.5°F) while becoming stiff and unresponsive. Before emergency medical service arrival, his friends placed cold compresses on the patient and rested him in an ice filled bathtub. DIAGNOSES Per history from patient's friends and toxicology results, the patient was diagnosed with ecstasy overdose, which evolved to include protracted hyperthermia and delayed rhabdomyolysis. INTERVENTIONS Due to a Glasgow coma scale score of 5, he was intubated and sedated with a propofol maintenance. Hyperpyrexia resolved (temperature dropped to 99.1°F) after start of propofol maintenance. He was extubated after 24 hours, upon which he experienced hyperthermia (101.4°F at 48 hours), delayed rhabdomyolysis, and DIC (onset at 37 hours). He remained in hyperthermia for 120 hours until carvedilol permanently returned his temperature to baseline. His plasma CK reached a peak of 409,440 U/L at 35 hours. OUTCOMES After primary management with intravenous fluids, the patient returned to baseline health without any consequences and was discharged after 8 days. A follow-up of 3 months postdischarge revealed no complications or disability. LESSONS Clinically, the case highlights how physicians should be aware of the unusual time course adverse effects of ecstasy can have. Lastly, as intensity and duration of hyperpyrexia are predictors of mortality, our case indicates maintenance of sedation with propofol and use of oral carvedilol; both are efficacious for temperature reduction in ecstasy toxicity.
Collapse
Affiliation(s)
- Arash Ghaffari-Rafi
- University of Hawaiʻi at Mānoa, John A. Burns School of Medicine, Honolulu, HI
- University College London, Queen Square Institute of Neurology, London, UK
| | - Ki Suk Eum
- Tripler Army Medical Center, Department of Medicine, Honolulu, HI
| | - Jesus Villanueva
- Tripler Army Medical Center, Department of Medicine, Honolulu, HI
| | - Jay Jahanmir
- University of Hawaiʻi at Mānoa, John A. Burns School of Medicine, Honolulu, HI
- Tripler Army Medical Center, Department of Medicine, Honolulu, HI
| |
Collapse
|
4
|
Considering the context: social factors in responses to drugs in humans. Psychopharmacology (Berl) 2018; 235:935-945. [PMID: 29470605 PMCID: PMC5871591 DOI: 10.1007/s00213-018-4854-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 02/06/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Drugs are typically used in social settings. Here, we consider two factors that may contribute to this observation: (i) the presence of other people may enhance the positive mood effects of a drug, and conversely, (ii) drugs may enhance the value of social stimuli. METHODS We review evidence from controlled laboratory studies with human volunteers, which investigated either of these interactions between social factors and responses to drugs. We examine the bidirectional effects of social stimuli and single doses of alcohol, stimulants, opioids, and cannabis. RESULTS All four classes of drugs interact with social contexts, but the nature of these interactions varies across drugs, and depends on whether the context is positive or negative. CONCLUSIONS Alcohol and stimulant drugs enhance the attractiveness of social stimuli and the desire to socialize, and social contexts, in turn, enhance these drugs' effects. In contrast, opioids and cannabis have subtler effects on social interactions and their effects are less influenced by the presence of others. Overall, there is stronger evidence that drugs enhance positive social contexts than that they dampen the negativity of unpleasant social settings. Controlled research is needed to understand the interactions between drugs of abuse and social contexts, to model and understand the determinants of drug use outside the laboratory.
Collapse
|
5
|
Abstract
Drug-induced status epilepticus (SE) is a relatively uncommon phenomenon, probably accounting for less than 5% of all SE cases, although limitations in case ascertainment and establishing causation substantially weaken epidemiological estimates. Some antiepileptic drugs, particularly those with sodium channel or GABA(γ-aminobutyric acid)-ergic properties, frequently exacerbate seizures and may lead to SE if used inadvertently in generalized epilepsies or less frequently in other epilepsies. Tiagabine seems to have a particular propensity for triggering nonconvulsive SE sometimes in patients with no prior history of seizures. In therapeutic practice, SE is most commonly seen in association with antibiotics (cephalosporins, quinolones, and some others) and immunotherapies/chemotherapies, the latter often in the context of a reversible encephalopathy syndrome. Status epilepticus following accidental or intentional overdoses, particularly of antidepressants or other psychotropic medications, has also featured prominently in the literature: whilst there are sometimes fatal consequences, this is more commonly because of cardiorespiratory or metabolic complications than as a result of seizure activity. A high index of suspicion is required in identifying those at risk and in recognizing potential clues from the presentation, but even with a careful analysis of patient and drug factors, establishing causation can be difficult. In addition to eliminating the potential trigger, management should be as for SE in any other circumstances, with the exception that phenobarbitone is recommended as a second-line treatment for suspected toxicity-related SE where the risk of cardiovascular complications is higher anyways and may be exacerbated by phenytoin. There are also specific recommendations/antidotes in some situations. The outcome of drug-induced status epilepticus is mostly good when promptly identified and treated, though less so in the context of overdoses. This article is part of a Special Issue entitled "Status Epilepticus".
Collapse
|
6
|
Abstract
ABSTRACTObjective:The use of dantrolene in the treatment of hyperpyrexia related to MDMA (3,4-methylenedioxymethamphetamine) is controversial, with little data available to guide clinical decision-making. Although the treatment is recommended by several poison control centres, published data are primarily in the form of case reports and animal and in vitro experiments. We conducted a systematic review to investigate the published evidence regarding the safety and benefits of dantrolene for MDMA-related hyperpyrexia in humans.Data sources:A systematic search of Embase and MEDLINE was conducted from the earliest possible date to November 2008.Study selection:All human trials and case reports of MDMA-related hyperpyrexia were considered.Data extraction:Data were abstracted systematically and characteristics including use of dantrolene, adverse reactions attributed to dantrolene, peak temperature, complications from MDMA-related hyperpyrexia and survival were recorded.Data synthesis:Our search yielded 668 articles of which 53, reporting 71 cases of MDMA-induced hyperpyrexia, met our inclusion criteria. No clinical trials, randomized controlled trials, observational studies or meta-analyses were identified. Dantrolene was used in 26 cases. Patient characteristics were similar in the dantrolene and no dantrolene groups. The proportion of survivors was higher in the dantrolene group (21/26) than in the no dantrolene group (25/45). This difference was especially pronounced in those with extreme (≥ 42°C) and severe (≥ 40°C) fever, with a survival rate of 8 of 13 and 10 of 10, respectively, in the dantrolene group compared with 0 of 4 and 15 of 27 in the no dantrolene group. There were no reports of adverse events attributable to dantrolene with the exception of a possible association with an episode of transient hypoglycemia.Conclusion:Our systematic review suggests that dantrolene is safe for patients with MDMA-related hyperpyrexia. Dantrolene may also be associated with improved survival and reduced complications, especially in patients with extreme (≥ 42°C) or severe (≥ 40°C) hyperpyrexia, although this conclusion must be interpreted with caution given the risk of reporting or publication bias.
Collapse
|
7
|
Campbell GA, Rosner MH. The agony of ecstasy: MDMA (3,4-methylenedioxymethamphetamine) and the kidney. Clin J Am Soc Nephrol 2008; 3:1852-60. [PMID: 18684895 DOI: 10.2215/cjn.02080508] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Ecstasy (MDMA, 3,4-methylenedioxymethamphetamine) is commonly used by college-aged individuals. Ecstasy leads to feelings of euphoria, emotional empathy, and increased energy. These effects come at a significant risk for complications. Ecstasy has been associated with acute kidney injury that is most commonly secondary to nontraumatic rhabdomyolysis but also has been reported in the setting of drug-induced liver failure and drug-induced vasculitis. More common, ecstasy has led to serious hyponatremia and hyponatremia-associated deaths. Hyponatremia in these cases is due to a "perfect storm" of ecstasy-induced effects on water balance. Ecstasy leads to secretion of arginine vasopressin as well as polydipsia as a result of its effects on the serotonergic nervous pathways. Compounding these effects are the ready availability of fluids and the recommendation to drink copiously at rave parties where ecstasy is used. The effects of ecstasy on the kidney as well as therapeutic measures for the treatment of ecstasy-induced hyponatremia are presented.
Collapse
Affiliation(s)
- Garland A Campbell
- Division of Nephrology, University of Virginia Health System, Department of Medicine, Charlottesville, VA 22908, USA
| | | |
Collapse
|
8
|
Hall AP, Henry JA. Acute toxic effects of ‘Ecstasy’ (MDMA) and related compounds: overview of pathophysiology and clinical management. Br J Anaesth 2006; 96:678-85. [PMID: 16595612 DOI: 10.1093/bja/ael078] [Citation(s) in RCA: 199] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Since the late 1980s 'Ecstasy' (3,4-methylenedioxymethamphetamine, MDMA) has become established as a popular recreational drug in western Europe. The UK National Criminal Intelligence Service estimates that 0.5-2 million tablets are consumed weekly in Britain. It has been reported that 4.5% of young adults (15-34 yr) in the UK have used MDMA in the previous 12 months. Clinically important toxic effects have been reported, including fatalities. While the phenomenon of hyperpyrexia and multi-organ failure is now relatively well known, other serious effects have become apparent more recently. Patients with acute MDMA toxicity may present to doctors working in Anaesthesia, Intensive Care and Emergency Medicine. A broad knowledge of these pathologies and their treatment is necessary for anyone working in an acute medical speciality. An overview of MDMA pharmacology and acute toxicity will be given followed by a plan for clinical management.
Collapse
Affiliation(s)
- A P Hall
- Department of Anaesthesia and Intensive Care Medicine, University Hospitals of Leicester NHS Trust, Leicester Royal Infirmary, Leicester LE1 5WW, UK.
| | | |
Collapse
|
9
|
Klingler W, Heffron JJA, Jurkat-Rott K, O'sullivan G, Alt A, Schlesinger F, Bufler J, Lehmann-Horn F. 3,4-Methylenedioxymethamphetamine (Ecstasy) Activates Skeletal Muscle Nicotinic Acetylcholine Receptors. J Pharmacol Exp Ther 2005; 314:1267-73. [PMID: 15947037 DOI: 10.1124/jpet.105.086629] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Adverse 3,4-methylenedioxymethamphetamine (MDMA; ecstasy) effects are usually ascribed to neurotransmitter release in the central nervous system. Since clinical features such as fasciculations, muscle cramps, rapidly progressing hyperthermia, hyperkalemia, and rhabdomyolysis point to the skeletal muscle as additional target, we studied the effects of MDMA on native and cultured skeletal muscle. We addressed the question whether malignant hyperthermia (MH)-susceptible (MHS) muscle is predisposed to adverse MDMA reactions. Force measurements on muscle strips showed that 100 microM MDMA, a concentration close to that determined in some MDMA users, regularly enhanced the sensitivity of skeletal muscle to caffeine-induced contractures but did not cause contractures on its own. The left-shift of the dose-response curve induced by MDMA was greater in normal than in MHS muscle. Furthermore, MDMA did not release Ca(2+) from isolated sarcoplasmic reticulum vesicles. These findings do not support the view of an MH-triggering effect on muscle. However, MDMA induced Ca(2+) transients in myotubes and increased their acidification rate. Surprisingly, alpha-bungarotoxin, a specific antagonist of the nicotinic acetylcholine receptor (nAChR), abolished these MDMA effects. The nAChR agonistic action of MDMA was confirmed by patch-clamp measurements of ion currents on human embryonic kidney cells expressing nAChR. We conclude that the neuromuscular junction is a target of MDMA and that an activation of nAChR contributes to the muscle-related symptoms of MDMA users. The drug may be of particular risk in individuals with abundant extrajunctional nAChR such as in generalized denervation or muscle regeneration processes and may act on central nAChR.
Collapse
|
10
|
Green AR, O'shea E, Colado MI. A review of the mechanisms involved in the acute MDMA (ecstasy)-induced hyperthermic response. Eur J Pharmacol 2004; 500:3-13. [PMID: 15464016 DOI: 10.1016/j.ejphar.2004.07.006] [Citation(s) in RCA: 111] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/01/2004] [Indexed: 11/29/2022]
Abstract
The predominant severe acute adverse effect following ingestion of 3,4-methylenedioxymethamphetamine (MDMA, ecstasy) by recreational users is hyperthermia which can induce other associated clinical problems and occasionally death. There is no pharmacologically specific treatment. MDMA also induces dose-dependent hyperthermia in experimental animals. This review examines the consequences of MDMA administration on body temperature in humans and rodents. In rats hyperthermia results primarily from dopamine release and is influenced by dose, ambient temperature and other housing conditions. The response is increased in rats with a prior MDMA-induced neurotoxic lesion of 5-hydroxytryptamine (5-HT) nerve endings. Increased MDMA-induced locomotor activity appears to play no role in the hyperthermic response. However, the size of the acute hyperthermic response plays a major role in determining the severity of the subsequent neurotoxicity. These results suggest that any MDMA-induced hyperthermic response will be enhanced in hot, crowded dance club conditions and that ingesting the drug in such conditions increases the possibility of subsequent cerebral neurotoxic effect.
Collapse
Affiliation(s)
- A Richard Green
- Neuropharmacology Research Group, School of Pharmacy, De Montfort University, The Gateway, Leicester LE1 9BH, UK.
| | | | | |
Collapse
|
11
|
|
12
|
Caldicott DGE, Edwards NA, Kruys A, Kirkbride KP, Sims DN, Byard RW, Prior M, Irvine RJ. Dancing with "death": p-methoxyamphetamine overdose and its acute management. JOURNAL OF TOXICOLOGY. CLINICAL TOXICOLOGY 2003; 41:143-54. [PMID: 12733852 DOI: 10.1081/clt-120019130] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Para-methoxyamphetamine (PMA) is a substituted synthetic amphetamine used in the recreational drug scene. It is unusual because of the high incidence of significant morbidity and mortality in overdose. We report a case of PMA overdose in South Australia, and review our experience with the drug. We review the literature on PMA overdose and offer suggestions on the management of overdose with this dangerous drug.
Collapse
Affiliation(s)
- David G E Caldicott
- Emergency Department, Royal Adelaide Hospital, North Terrace, Adelaide, Australia.
| | | | | | | | | | | | | | | |
Collapse
|
13
|
Abstract
Ecstasy is the second most widely abused illegal drug in Europe. Ecstasy is the colloquial name for 3,4-methylenedioxymethamphetamine (MDMA), but not all Ecstasy tablets contain MDMA. When taken in hot, crowded environments, Ecstasy/MDMA users have developed acute complications that have had fatal consequences. Epidemiological evidence indicates that adverse reactions to Ecstasy/MDMA intoxication are rare and idiosyncratic. Potential mechanisms of action are reviewed. In animal studies, MDMA damages serotonergic fibres and reduces the number of serotonin transporter sites within the CNS. Demonstration of neurotoxicity in human users of Ecstasy is hampered by a number of confounds that the majority of published studies have failed to address. These confounds are reviewed and their impact is discussed.
Collapse
Affiliation(s)
- J C Cole
- Psychology Department, Liverpool University, Liverpool L69 7ZA, UK.
| | | |
Collapse
|
14
|
Abstract
Increasing use of 3,4-methylenedioxymethamphetamine (MDMA, "Ecstasy") has been accompanied by concern about acute and possible long-term toxicity. This article discusses acute serious toxicity, chronic toxicity, and common problems associated with Ecstasy use, as well as the implications of these areas for prevention programs targeted at current Ecstasy users. The low incidence of serious adverse events in users creates difficulties for attempts to develop harm reduction recommendations. Many hypothesized risk factors for serious adverse events cannot be confirmed or denied and may not be associated with dramatic elevations in risk. Research on chronic toxicity in users provides strong evidence of neurophysiological changes and suggestive evidence of possible neurocognitive changes. Because these worrisome changes are clinically subtle, users may not be influenced by concerns of neurotoxicity. In contrast, common Ecstasy-related complaints are relatively well documented and have identified risk factors, including factors relating to extent of Ecstasy use (such as "binges"). Common complaints include modest acute and subacute adverse effects,some lasting several days, and problems in life. The apparent willingness of users to modify drug use and other behaviors to decrease these common problems could be used by harm reduction or other prevention programs to encourage users to decrease the extent of Ecstasy use.
Collapse
|
15
|
Abstract
"Club drugs" have become alarmingly popular. The use of 3,4-methylenedioxymethamphetamine (MDMA, Ecstasy) and gamma-hydroxybutyrate (GHB), in particular, has increased dramatically from 1997-1999. The pharmacokinetics of MDMA and GHB appear to be nonlinear, making it difficult to estimate a dose-response relationship. The drug MDMA is an amphetamine analog with sympathomimetic properties, whereas GHB is a gamma-aminobutyric acid analog with sedative properties. Symptoms of an MDMA toxic reaction include tachycardia, sweating, and hyperthermia. Occasional severe sequelae include disseminated intravascular coagulation, rhabdomyolysis, and acute renal failure. Treatment includes lowering the body temperature and maintaining adequate hydration. Symptoms of GHB intoxication include coma, respiratory depression, unusual movements, confusion, amnesia, and vomiting. Treatment includes cardiac and respiratory support. Because of the popularity of these agents and their potentially dangerous effects, health care professionals must be familiar with these substances and the treatment options for patients who present with symptoms of a toxic reaction.
Collapse
Affiliation(s)
- C J Teter
- College of Pharmacy, University of Michigan, Ann Arbor 48109-1065, USA.
| | | |
Collapse
|