Hyperthermia associated with 3,4-methylenedioxyethamphetamine ('Eve')

Hard Boiled: Alcohol Use as a Risk Factor for MDMA-Induced Hyperthermia: a Systematic Review

Although MDMA (ecstasy) is a relatively safe recreational drug and is currently considered for therapeutic use for the treatment of posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD), recreational MDMA use occasionally elicits hyperthermia and hyponatremia, sometimes with a fatal outcome. Specific risk factors for both adverse effects are profuse sweating while vigorously dancing under unfavorable conditions such as high ambient temperatures and insufficient fluid suppletion which result in dehydration. Concomitant use of MDMA and alcohol is highly prevalent, but adds to the existing risk, because alcohol facilitates the emergence of MDMA-induced adverse events, like hyperthermia, dehydration, and hyponatremia. Because of potential health-related consequences of concomitant use of MDMA and alcohol, it is important to identify the mechanisms of the interactions between alcohol and MDMA. This review summarizes the main drivers of MDMA-induced hyperthermia, dehydration, and hyponatremia and the role of concomitant alcohol use. It is shown that alcohol use has a profound negative impact by its interaction with most of these drivers, including poikilothermia, exposure to high ambient temperatures, heavy exercise (vigorous dancing), vasoconstriction, dehydration, and delayed initiation of sweating and diuresis. It is concluded that recreational and clinical MDMA-users should refrain from concomitant drinking of alcoholic beverages to reduce the risk for adverse health incidents when using MDMA.

Pharmacology of Drugs Used as Stimulants

Psychostimulant, cardiovascular, and temperature actions of stimulants involve adrenergic (norepinephrine), dopaminergic (dopamine), and serotonergic (serotonin) pathways. Stimulants such as amphetamine, 3,4-methylenedioxymethamphetamine (MDMA), or mephedrone can act on the neuronal membrane monoamine transporters NET, DAT, and SERT and/or the vesicular monoamine transporter 2 to inhibit reuptake of neurotransmitter or cause release by reverse transport. Stimulants may have additional effects involving pre- and postsynaptic/junctional receptors for norepinephrine, dopamine, and serotonin and other receptors. As a result, stimulants may have a wide range of possible actions. Agents with cocaine or MDMA-like actions can induce serious and potentially fatal adverse events via thermodysregulatory, cardiovascular, or other mechanisms. MDMA-like stimulants may cause hyperthermia that can be life threathening. Recreational users of stimulants should be aware of the dangers of hyperthermia in a rave/club environment.

Dantrolene in the treatment of MDMA-related hyperpyrexia: a systematic review

Objective:

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.

Ecstasy (3, 4-methylenedioxymethamphetamine) use among Japanese rave population

AIMS

The aim of this study was to examine the prevalence of 3, 4-methylenedioxymethamphetamine (MDMA) use and to identify characteristics of MDMA users among rave attendees in Japan. This is the first rave-population study focusing on MDMA use in Japan.

METHODS

The anonymous self-administrative questionnaire was conducted using laptop computers at four rave parties at three different venues in Tokyo, Japan. Participants were asked about lifetime use of MDMA and other club drug use, characteristics of rave attendance, and their demographics.

RESULTS

Questionnaires were completed by 300 rave attendees (47.3% female), 68.3% of whom were aged 20-29 years, and 92.3% of whom had completed high school. Among the participants, 8.0% reported MDMA use. Compared with 'non-drug controls' (the participants who had never used any illicit drugs), MDMA users were significantly more likely to be 30-39-year-old men. In addition, compared with 'cannabis users' (non-MDMA users who had used cannabis), MDMA users were significantly more likely to use other drugs and reported more adverse health effects due to 'polydrug use'. Furthermore, MDMA users were significantly more likely to go to raves and preferred smaller venues.

CONCLUSIONS

Our results clearly suggest that rave attendees have a higher lifetime prevalence of MDMA use than the Japanese general population (0.2% reported in 2007). MDMA users are deeply involved in rave parties, and MDMA use may have high potential to generate close relationships among rave attendees. Therefore, MDMA users may have more opportunities to access MDMA than cannabis users and non-drug controls.

Maligne Hyperthermie

The term "malignant hyperthermia" (MH), regarded as the typical anaesthetic disease, refers to a clinical syndrome of varying intensity (from abortive courses to fulminant crises) and develops only under exposure of certain triggering substances or mechanisms. MH is caused by a defect in the ryanodine receptor subtype 1, which can often be proved genetically. Furthermore, it may also be generated by other mechanisms which disturb the membranous integrity of skeletal muscle cells (e.g. some myotonias, muscular dystrophies, malformation syndromes). Hyperthermia is only one of a number of life-threatening symptoms that may occur during a fulminant crisis, which ultimately results from an excessive release of calcium into the cytoplasm of muscle cells. Due to a current good knowledge about classical triggers, symptoms and therapeutic interventions, a clinical MH presentation may successfully be treated in the perioperative period. However, it appears to be likely that there are unreported cases outside hospitals since atypical courses or alternative MH triggers (e.g. alcohol, drugs, physical stress) may impair the correct diagnosis. In contrast severe hyperthermia can also arise from other drug-induced diseases, e.g. the neuroleptic malignant syndrome or the serotonin syndrome.

Apparent active transport of MDMA is not mediated by P-glycoprotein: a comparison with MDCK and Caco-2 monolayers

Amphetamines and their methylenedioxy derivatives generically display similar behavioral, physiologic and toxic effects. Inconsistent pharmacokinetic and toxicity data for methylenedioxymethamphetamine (MDMA) may suggest that active drug transporters are interacting with these compounds, and thus altering drug absorption and tissue distribution. In vitro models of CNS accumulation and intestinal drug transport were used to assess efflux transport of MDMA. Madin-Darby kidney cell epithelial (MDCK) monolayers displayed a 4-fold increase in accumulation in the basolateral to apical orientation relative to the apical to basolateral orientation, although no differential accumulation was noted between MDCK-WT and MDCK-MDR1 monolayers. Caco-2 monolayers demonstrated an approximate 2-fold increase in accumulation of MDMA. Exposure of various inhibitors of active drug transporters demonstrated mixed results; ritonavir, progesterone and indomethacin produced an approximately 50% reduction of MDMA transport, while verapamil, MK-571 and probenecid had no effect. Based on these data, it is concluded that MDMA efflux is mediated via the activity of a transporter distinct from P-glycoprotein. The possible inhibitory effects of amphetamines on rhodamine-123 transport were also assessed. MDMA, methylenedioxyamphetamine, amphetamine and methamphetamine, at physiologically relevant concentrations, did not significantly alter the transport of rhodamine-123 in Caco-2 monolayers or the LS180 cell line, suggesting that these compounds do not alter the function of P-glycoprotein.

Context-dependent behavioural and neuronal sensitization in striatum to MDMA (ecstasy) administration in rats

To investigate the neuronal mechanisms underlying the behavioural alterations that accompany repeated exposure to MDMA (ecstasy), we recorded the activity of > 200 striatal units in response to multiple, intermittent, locomotor-activating doses (5.0 mg/kg) of MDMA. Rats were treated with once-daily injections of either saline or MDMA for 5 days when housed in their home cage, followed by a challenge injection 3-5 days later when housed in a recording chamber. Because contextual drug associations might be particularly important to the expression of behavioural sensitization to chronic MDMA, a separate group of rats received repeated injections of MDMA alternately in the recording chamber or home cage, according to the above timeline. A sensitized locomotor response was observed only in rats that had previously experienced MDMA in the context of the recording chamber, and only on the challenge day. These sensitized animals also showed a decreased basal firing rate in neurons that were subsequently excited by MDMA when compared with the same category of neurons earlier in the treatment regimen. This resulted in a greater percentage increase from the baseline firing rate on the challenge day compared with the first and fifth days of treatment, even though this trend was not evident with an analysis of absolute firing rate. These results strongly support a role for context in the expression of MDMA-induced locomotor sensitization, and implicate striatal involvement in the neurobehavioural changes associated with the repeated use of MDMA.

Acute toxic effects of ‘Ecstasy’ (MDMA) and related compounds: overview of pathophysiology and clinical management

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.

Methylenedioxymethamphetamine (ecstasy)-related hyperthermia

MDMA (or 3, 4 methylenedioxymethamphetamine) was first manufactured in the 1920s and found to have structural similarities to both mescaline and amphetamines. Used briefly by some therapists in the 1970s and early 1980s as an adjunct to psychotherapy, it is now primarily abused by teenagers and young adults as an illicit recreational drug known as "ecstasy." As its popularity has increased, so have the number of fatalities and adverse events related to its use. We report six patients suffering fatal or life-threatening hyperthermia after MDMA use. These cases illustrate that hyperthermia associated with MDMA use cannot be solely attributed to rave parties (high ambient temperatures, excessive dancing, dehydration, and overcrowded conditions), drug contaminants, or co-ingestants. A better understanding of the etiology of hyperthermia after MDMA use is needed so that appropriate harm-reduction measures can be developed and instituted.

The Neuropsychopharmacology and Toxicology of 3,4-methylenedioxy-N-ethyl-amphetamine (MDEA)

This paper reviews the pharmacology and toxicology of 3,4-methylenedioxy-N-ethylamphetamine (MDEA, "eve"). MDEA is a ring-substituted amphetamine (RSA) like MDMA, its well known N-methyl analog. Both have become very popular substances of abuse in the techno- and house-music scene. They can evoke psychomotor stimulation, mild alterations of perception, sensations of closeness and a positive emotional state as well as sympathomimetic physical effects. At present, the name "ecstasy" is no longer used only for MDMA, but for the whole group of RSAs (MDA, MDMA, MDEA and MBDB) as they are chemically and pharmacologically nearly identical; moreover, many ecstasy pills contain mixtures of the RSAs. Hence, for a selective review on MDEA, it is crucial to strictly differentiate between: 1) street and chemical names, and 2) studies with or without chemically defined substances. In order to present MDEA-specific information, the pharmacodynamics and kinetics are described on the basis of MDEA challenge studies in animals and humans. In the toxicology section, we present a collection of case reports on fatalities where MDEA was toxicologically confirmed. On the question of serotonergic neurotoxicity and possible long-term consequences, however, MDEA-specific information is available from animal studies only. The neurotoxic potential of MDEA in humans is difficult to estimate, as ecstasy users do not consume pure substances. For future research, challenge studies in animals using dosing regimens adapted to human consumption patterns are needed. Such challenge studies should directly compare individual RSAs. They will represent the most viable and fruitful approach to the resolution of the highly controversial issues of serotonergic neurotoxicity and its functional consequences.

???Ecstasy??? intoxication: life-threatening manifestations and resuscitative measures in the intensive care setting

OBJECTIVE

The ingestion of 3,4-methylenedioxymethamphetamine ('ecstasy') can cause severe neurological impairment and multi-system damage. We describe the potentially life-threatening clinical features and the management of intoxication by this psychedelic drug in patients transferred from emergency services to the intensive care area.

METHODS

We conducted a retrospective analysis of 'ecstasy'-intoxicated patients admitted to a municipal hospital during a three-month period.

RESULTS

Of the 32 patients brought to the emergency services, three (9.3%; mean age 21+/-2 years) were transferred to the intensive care area in a comatose state associated with seizures after ingesting one to three tablets of 150 mg 3,4-methylenedioxymethamphetamine. All required artificial ventilation and none responded to painful stimuli. The brain computed tomography scan and lumbar puncture results were normal. The main clinical manifestations were hyponatremia, high fever, rhabdomyolysis, dehydration and metabolic acidosis accompanied by impaired liver and renal functions. All three patients regained consciousness after 2.1+/-0.8 days of system-oriented supportive care and were discharged for further surveillance in medical wards after 4.3+/-2.1 days.

CONCLUSION

The increase in life-threatening episodes of 3,4-methylenedioxymethamphetamine intoxication that mandate admission, treatment and close surveillance in an intensive care milieu make it incumbent to establish appropriate management protocols for minimizing immediate mortality and late morbidity.

The health effects of ecstasy: a literature review

Ecstasy (3,4-methylenedioxymethamphetamine, MDMA) is the third most used illicit drug, after cannabis and amphetamines. There has been considerable interest in the adverse effects of use, with particular attention given to a small number of deaths related to ecstasy use, and the neurotoxic effects of MDMA. This paper reviews case reports of adverse effects attributed to ecstasy use, and the findings of animal and human studies, so as to identify the health effects of ecstasy use, and factors contributing to their occurrence. The incidence of serious acute adverse events related to ecstasy is low. It is the unpredictability of those adverse events and the risk of mortality and substantial morbidity that makes the health consequences of ecstasy significant. Hyperthermia and hyponatraemia are the most significant acute adverse effects, and can occur even when MDMA is the only drug used. Ecstasy users should be aware of the importance of controlling body temperature and fluid intake, early signs of adverse effects, and the need to seek medical assistance promptly. Neurotoxicity is potentially the most significant long-term effect of ecstasy. The clinical implications of neurotoxicity are uncertain at this time, but short-term memory impairment may be significant.

Serotonergic deficits and impaired passive-avoidance learning in rats by MDEA: a comparison with MDMA

The serotonergic deficits induced by 3,4-methylenedioxyethamphetamine (MDEA, "eve"), were examined and compared with 3,4 methylenedioxymethamphetamine (MDMA, "ecstasy"). A single dose of MDEA (10, 20, or 40 mg/kg IP) induced a dose-related hyperthermia, but only the highest dose significantly reduced 5-HT content and 5-HT transporter density in the frontal cortex and in the hippocampus 7 days later. Long-term serotonergic deficits were much more marked when MDEA was given repeatedly (40 mg/kg IP., b.i.d., for 4 consecutive days). Single or repeated administration of MDEA induced no change on 5-HT1A receptor density in the frontal cortex, brain stem, or hippocampus, although 3 h after both treatments plasma corticosterone levels were significantly increased. MDEA (5-20 mg/kg, IP) produced significant retention deficits in a passive-avoidance learning task. Conversely, 7 days after the repeated administration of MDEA (40 mg/kg b.i.d., for 4 consecutive days) no effect on passive-avoidance performance was observed unless rats were treated again with another dose of MDEA (20 mg/kg IP) 30 min before the training trial. The 5-HT1A receptor antagonist, WAY 100635, prevented the impairment in retention performance induced by 8-hydroxy-2-(di-n-propylamino)tetralin (8-OH-DPAT), but not by MDEA or MDMA, indicating that the effect of these amphetamine derivates was not mediated by 5-HT1A receptor activation. The results suggest the risk of serotonergic dysfunction associated with MDEA abuse in humans.

The acute effect in rats of 3,4-methylenedioxyethamphetamine (MDEA, "eve") on body temperature and long term degeneration of 5-HT neurones in brain: a comparison with MDMA ("ecstasy")

Administration of a single dose of the recreationally used drug 3,4-methylenedioxyethamphetamine (MDEA or "eve") to Dark Agouti rats resulted in an acute dose-dependent hyperthermic response. The peak effect and duration of hyperthermia of a dose of MDEA of 35 mg/kg intraperitoneally was similar to a dose of 3,4-methylenedioxymethamphetamine (MDMA or "ecstasy") of 15 mg/kg intraperitoneally. Seven days later this dose of MDMA produced a marked (approximately 50%) loss of 5-HT and its metabolite 5-HIAA in cortex, hippocampus and striatum and a similar loss of [3H]-paroxetine binding in cortex: these losses reflecting the MDMA-induced neurotoxic degeneration of 5-HT nerve endings. In contrast, administration of MDEA (15, 25 or 35 mg/kg), even at the highest dose, produced only a 20% loss in cortex and hippocampus and no decrease in striatum. The neurotoxic effect of MDEA was only weakly dose-dependent. Neither MDEA (35 mg/kg) nor MDMA (15 mg/kg) altered striatal dopamine content 7 days later. MDEA appeared to have about half the potency of MDMA in inducing acute hyperthermia and 25% of the potency in inducing degeneration of cerebral 5-HT neurones. However since higher doses of MDEA (compared to MDMA) are probably necessary to induce mood changing effects, these data do not support any contention that this compound is a "safer" recreational drug than MDMA in terms of either acute toxicity or long term neurodegeneration.

3,4-Methylenedioxy analogues of amphetamine: defining the risks to humans

The 3,4-methylenedioxy analogues of amphetamine [MDMA ("Ecstasy", "Adam"), MDA ("Love") and MDE ("Eve")] are recreational drugs that produce feelings of euphoria and energy and a desire to socialize, which go far to explain their current popularity as "rave drugs". In addition to these positive effects, the drugs are relatively inexpensive to purchase and have the reputation of being safe compared to other recreational drugs. Yet there is mounting evidence that these drugs do not deserve this reputation of being safe. This review examines the relevant human and animal literature to delineate the possible risks MDMA, MDA and MDE engender with oral consumption in humans. Following a summary of the behavioral and cognitive effects of MDMA, MDA and MDE, risks will be discussed in terms of toxicity, psychopathology, neurotoxicity, abuse potential and the potential for drug-drug interactions associated with acute and chronic use.

Detection of designer drugs in human hair by ion mobility spectrometry (IMS)

Since its inception in the early 1970s under the name plasma chromatography, ion mobility spectrometry (IMS) has undergone great changes. It is now utilized more and more in forensic science laboratories where it is used to detect explosives and environmental pollutants [1-4] as well as its use in detecting drugs of abuse [5-8]. Although IMS is known for nearly 30 years now [9], relatively few cases of the application of ion mobility spectrometry to the analysis of human hair have been reported [10-12]. The authors report a new and quick method to rapidly screen and determine MDMA ('ecstasy', 'Adam') and MDEA ('Eve') in human hair. The proposed method using trihexylamine as internal standard resulted in a rapid procedure useful in screening human hair specimens for designer drugs.

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.

Lethal monointoxication by overdosage of MDEA

A 19-year-old man died after the intake of ten tablets of Ecstasy containing 3,4-methyl-enedioxy-N-ethylamphetamine (MDEA) as the main active ingredient. According to an eyewitness the symptoms of intoxication were strong sweating, sudden aggressiveness followed by hallucinations, subsequent failure of motoric coordination, severe spasms of arms and back, complete depression of the respiratory system, unconsciousness, and collapse. Resuscitation by an emergency doctor failed. Major autopsy findings were severe vascular congestion of all internal organs, liquid post-mortem blood, numerous subpleural and subepicardial petechial haemorrhages. By GC/MS analysis, MDEA was found in large amounts in serum (12 mg/l in femoral vein, 22 mg/l in heart blood serum), urine (201 mg/l), brain (18 to 28 mg/l) and in other tissue samples. Scalp-hair was highly positive for MDEA (17 ng/mg). Besides MDEA and its metabolites only trace amounts of MDMA could be found in urine and blood; no other drugs were detected. It can be concluded that the cause of death was a monointoxication by overdosage of MDEA.

Liver disease due to illicit substance use

While the adverse neurological, cardiovascular, renal, haematologic and musculoskeletal consequences of the use of various illicit substances are widely appreciated, less attention has been directed to possible hepatotoxic effects. This is an important issue in view of increasing evidence in both experimental animals and humans that the use of some illicit substances may be associated with substantial liver damage, leading on occasion to acute liver failure. This manuscript reviews the effects on the liver of some of the most commonly used illicit substances, including ecstasy (3,4-methylenedioxymethamphetamine), other amphetamines, cocaine, heroin, angel dust (phencyclidine), lysergic acid diethylamide and marijuana. Additional causes of liver damage in those using illicit substances are discussed.

Serotonin syndrome. A clinical update

Serotonin syndrome is characterized by varied degrees of cognitive, autonomic, and neuromuscular dysfunction and can only be produced by drug therapy that increases central nervous system serotonin neurotransmission. Information gained from a retrospective review of 127 cases of serotonin syndrome is presented. It is not uncommon for severe cases of serotonin syndrome to be confused with neuroleptic malignant syndrome. Treatment is mainly supportive, but specific pharmacologic therapy with serotonin antagonists may be potentially beneficial.

MDMA induced hyperthermia: a survivor with an initial body temperature of 42.9 degrees C

A young male survived hyperpyrexia (42.9 degrees C) following MDMA ("Ecstasy") ingestion. He developed convulsions, rhabdomyolysis, metabolic acidosis, and respiratory failure. This was successfully managed by assisted ventilation, aggressive fluid therapy, and the early administration of dantrolene, in addition to cooling measures. This is the first report of a survivor with such a severe hyperpyrexia.

An unusual case of Ecstasy poisoning

We describe a case of poisoning with 3,4-methylenedioxymet-amphetamine Ecstasy that presented with all the features suggestive of a fatal outcome, including a creatinine phosphokinase level markedly higher than any previously reported. The patient, a paraplegic, was treated with dantrolene and made a full recovery.

Acute poisoning with amphetamines (MDEA) and heroin: antagonistic effects between the two drugs

A case of oral ingestion of large doses of both the amphetamine-derivative 3,4-methylene dioxyethamphetamine (MDEA) and heroin is reported. Despite high serum levels of both drugs, the patient did not present with the classic signs and symptoms normally seen during intoxication with these drugs. The patient recovered after symptomatic treatment. The possibility that opposite pharmacological properties of the two drugs prevented the patients death is discussed.

Acute liver damage and ecstasy ingestion

Eight cases of ecstasy related acute liver damage referred to a specialised liver unit are described. Two patients presented after collapse within six hours of ecstasy ingestion with hyperthermia, hypotension, fitting, and subsequently disseminated intravascular coagulation with rhabdomyolysis together with biochemical evidence of severe hepatic damage. One patient recovered and the other with evidence of hyperacute liver failure was transplanted but subsequently died, histological examination showing widespread microvesicular fatty change. Four patients presented with acute liver failure without hyperthermia. All four fulfilled criteria for transplantation, one died before a donor organ became available, and two died within one month post-transplantation of overwhelming sepsis. Histological examination showed submassive lobular collapse. Two patients presented with abdominal pain and jaundice and recovered over a period of three weeks; histological examination showed a lobular hepatitis with cholestasis. Patients developing jaundice or with evidence of hepatic failure particularly encephalopathy and prolongation of the international normalised ratio, or both, whether or not preceded by hyperthermia, should be referred to a specialised liver unit as liver transplantation probably provides the only chance of recovery.

Pathology of deaths associated with "ecstasy" and "eve" misuse

AIMS

To study the postmortem pathology associated with ring substituted amphetamine (amphetamine derivatives) misuse.

METHODS

The postmortem findings in deaths associated with the ring substituted amphetamines 3,4-methylenedioxymethyl-amphetamine (MDMA, ecstasy) and 3,4-methylenedioxyethylamphetamine (MDEA, eve) were studied in seven young white men aged between 20 and 25 years.

RESULTS

Striking changes were identified in the liver, which varied from foci of individual cell necrosis to centrilobular necrosis. In one case there was massive hepatic necrosis. Changes consistent with catecholamine induced myocardial damage were seen in five cases. In the brain perivascular haemorrhagic and hypoxic changes were identified in four cases. Overall, the changes in four cases were the same as those reported in heart stroke, although only two cases had a documented history of hyperthermia. Of these four cases, all had changes in their liver, three had changes in their brains, and three in their heart. Of the other three cases, one man died of fulminant liver failure, one of water intoxication and one probably from a cardiac arrhythmia associated with myocardial fibrosis.

CONCLUSIONS

These data suggest that there is more than one mechanism of damage in ring substituted amphetamine misuse, injury being caused by hyperthermia in some cases, but with ring substituted amphetamines also possibly having a toxic effect on the liver and other organs in the absence of hyperthermia.

Hyperthermia following MDMA administration in rats: effects of ambient temperature, water consumption, and chronic dosing

In two experiments it was found that the hyperthermia which follows MDMA ("Ecstasy") results from an interaction of direct pharmacological effect of the drug and the prevailing environmental conditions in which it is administered. In Experiment 1, rats given fixed doses of either 2.5, 5.0 or 7.5 mg/kg MDMA or saline were injected on different days at ambient temperatures (Ta's) of 11, 24, and 30 degrees C. At each Ta drinking water was freely available following dosing on one session and temporarily unavailable on a second. The hyperthermic and hyperkinetic responses were monitored using remote biotelemetry. Experiment 2 used a between-subject design in which each group of rats received a standard 7.5 mg/kg dose of MDMA administered at only one of the three levels of Ta(24 degrees C) and at only one level of the water-availability factor. Dosing in some groups was continued for a further 13 days to test for tolerance or sensitization effects. Ambient temperature significantly affected the magnitude of the hyperthermia but not the hyperkinesis. Water deprivation during the drugged period significantly augmented the hyperthermia, but only in the high Ta (30 degrees C.) condition. Chronic dosing produced sensitization of both hyperthermic and hyperkinetic responses. The findings indicate that ambient temperature, water consumption and frequency of drug use affect the hyperthermia which follows MDMA administration.

Analysis of the enantiomers of 3,4-methylenedioxy-N-ethylamphetamine (MDE, "Eve") and its metabolite 3,4-methylenedioxyamphetamine (MDA) in rat brain

The methylenedioxy analogues of amphetamine are used recreationally despite concerns raised regarding potential neurotoxicity of the parent compounds and a number of metabolites. Much has been written regarding 3,4-methylenedioxymethamphetamine (MDMA; 3,4-methylenedioxy-N-ethylamphetamine (MDE; "Eve"), despite recent reports indicating the abuse of this drug and its potentially serious side effects. An assay procedure was developed for the simultaneous quantitation of both enantiomers of MDE and its metabolite MDA; the method involves derivatization with an optically pure reagent and analysis on a gas chromatograph equipped with a capillary column and a nitrogen-phosphorus detector. Brain levels of the enantiomers of MDE and MDA were examined in the rat at different time periods after acute i.p. injections of racemic MDE and the results were compared with levels of MDMA and MDA obtained after i.p. injection of MDMA in a previous study from our laboratories. The levels of the enantiomers of MDE and MDA achieved at 1, 4, and 8 hr were lower than in the case of MDMA. Stereoselective differences in brain levels of enantiomers of the parent drug and metabolite were much less marked with MDE than with MDMA, but where these small differences did exist in the case of MDE, the (R)-(-) vs (S)-(+) relationship was opposite to that reported for MDMA.