Cerebral venous sinus thrombosis induced by 'ecstasy'

The entactogen 3,4-methylenedioxymethamphetamine (MDMA; ecstasy) as a treatment aid in psychotherapy and its safety concerns

The phenylethylamine, 3,4-methylenedioxymethamphetamine (MDMA, 'ecstasy'), is the prototypical example of an entactogen. Its original placement in highly restrictive drug usage categories in the US and UK, led to an inevitable restriction on MDMA neuroscience research and treatment. The dominant pharmacological effects of MDMA are its properties of release and inhibition of reuptake of amine neurotransmitter transporters for dopamine, norepinephrine, and serotonin. MDMA is an agonist of a wide range of receptors; its mood-altering effects are mediated via 5-HT2A receptors; this receptor may also mediate its effects on body temperature, analgesia, and anxiolytic properties. The mechanisms underlying MDMA's entactogenic properties of sociability and interpersonal closeness are not known but release and involvement of oxytocin, a peptide thought by some to be involved in social bonding, has been suggested. Adverse effects of MDMA are mostly transient; acute multiorgan adverse effects occurring during raves or crowded dance gatherings include dehydration, hyperthermia, seizures, rhabdomyolysis, disseminated intravascular coagulation, and acute renal failure. Deaths following MDMA taken by itself are rare compared to fatalities following coadministration with other drugs. A recent FDA-approved phase 3 clinical trial of MDMA for post-traumatic stress disorder (PTSD) led to the conclusion that MDMA-assisted therapy represents a potential breakthrough treatment meriting expedited clinical evaluation. Despite the ongoing deliberations by the FDA and EMA for approval of MDMA treatment of PTSD, the Australian Therapeutic Goods Administration (TGA) recently announced that after an evaluation of the therapeutic value, benefits, and risks of MDMA, it will permit its prescribing for the treatment of PTSD. Further examples of regulatory relaxation toward MDMA-assisted psychotherapy are underway. These include the FDA's recently approved clinical trial to assess MDMA's efficacy in the treatment of "asociality" in patients with schizophrenia and an open trial of MDMA treatment for alcohol-use disorder which showed decreased alcohol consumption. There are also ongoing studies on the little understood startle response, anxiety associated with life-threatening illness, and social anxiety in autistic adults.

Ecstasy (3,4-methylenedioxymethamphetamine): Cardiovascular effects and mechanisms

3,4-methylenedioxymethamphetamine or MDMA (known as "ecstasy") is a recreational drug of abuse, popular worldwide for its distinctive psychotropic effects. Currently, the therapeutic potential of MDMA in psychotherapy has attracted a lot of interest from the scientific community, despite the multitude of effects that this drug of abuse elicits on the human body. While neuronal effects have been the most studied, cardiovascular effects have also been described, as increased blood pressure and heart rate are the most recognizable. However, other effects have also been described at the cardiac (impaired cardiac contractile function, arrhythmias, myocardial necrosis and valvular heart disease) and vascular (vasoconstriction, disruption of vascular integrity and altered haemostasis) levels. Several mechanisms have been proposed, from the interaction with monoamine transporters and receptors to the promotion of oxidative stress or the activation of matrix metalloproteinases (MMPs). This review provides an overview of the cardiovascular implications of MDMA intake and underlying mechanisms, relevant when considering its consumption as drug of abuse but also when considering its therapeutic potential in psychiatry. Moreover, the risk/benefit ratio of the therapeutic use of MDMA remains to be fully elucidated from a cardiovascular standpoint, particularly in patients with underlying cardiovascular disease.

Cyclosporine-A-Induced Intracranial Thrombotic Complications: Systematic Review and Cases Report

This study reported two cases of intracranial thrombotic events of aplastic anemia (AA) under therapy with cyclosporine-A (CsA) and reviewed both drug-induced cerebral venous thrombosis (CVT) and CsA-related thrombotic events systematically. We searched PubMed Central (PMC) and EMBASE up to Sep 2019 for publications on drug-induced CVT and Cs-A-induced thrombotic events. Medical subject headings and Emtree headings were used with the following keywords: "cyclosporine-A" and "cerebral venous thrombosis OR cerebral vein thrombosis" and "stroke OR Brain Ischemia OR Brain Infarction OR cerebral infarction OR intracerebral hemorrhage OR intracranial hemorrhage." We found that CsA might be a significant risk factor in inducing not only CVT but also cerebral arterial thrombosis in patients with AA.

Mephedrone and MDMA: A comparative review

Mephedrone and MDMA are both constituents of party drugs, with mephedrone being relatively new compared to MDMA. This review compares current knowledge regarding the patterns of usage and neuropsychobiological effects of both mephedrone and MDMA. Both drugs share common psychoactive effects, the duration of which is significantly shorter with mephedrone use, attributing towards a pattern of binge use among users. Both drugs have also been associated with adverse health, psychiatric, and neurocognitive problems. Whilst there is extensive research into the psychobiological problems induced by MDMA, the evidence for mephedrone is comparatively limited. The adverse effect profile of mephedrone appears to be less severe than that of MDMA. Users often believe it to be safer, although both drugs have been associated with overdoses. The neurotoxic potential of mephedrone appears to be low, whereas MDMA can cause long-term damage to the serotonergic system, although this needs further investigation. The abuse liability of mephedrone is significantly greater than that of MDMA, raising concerns regarding the impact of lifetime usage on users. Given that mephedrone is relatively new, the effects of long-term exposure are yet to be documented. Future research focused on lifetime users may highlight more severe neuropsychobiological effects from the drug.

Cyclosporin A-related cerebral venous sinus thrombosis: A case report

RATIONALE

Cerebral venous sinus thrombosis (CVST) is a complex life-threatening condition, and its etiology is not well understood. Although oral cyclosporin A is not a common cause of the symptoms related to CVST, there is limited information available.

PATIENT CONCERNS

In this study, we report a rare case of CVST in a 44-year-old woman with aplastic anemia, who was given cyclosporin A orally for a period of 18 months. She had experienced a headache for 20 days.

DIAGNOSES

The patient was diagnosed with CVST by computed tomography venography.

INTERVENTIONS

Low molecular heparin (enoxaparin, 4000 AXaIU, subcutaneous injection, once every 12 hours) was administered for anticoagulation.

OUTCOMES

The patient developed no recurrence of thrombosis during the 13-month follow-up period.

LESSONS

Clinicians should be aware of the possibility of CVST when patients are treated with cyclosporin A and have symptoms such as headaches.

MDMA-assisted therapy: A new treatment model for social anxiety in autistic adults

The first study of 3,4-methylenedioxymethamphetamine (MDMA)-assisted therapy for the treatment of social anxiety in autistic adults commenced in the spring of 2014. The search for psychotherapeutic options for autistic individuals is imperative considering the lack of effective conventional treatments for mental health diagnoses that are common in this population. Serious Adverse Events (SAEs) involving the administration of MDMA in clinical trials have been rare and non-life threatening. To date, MDMA has been administered to over 1133 individuals for research purposes without the occurrence of unexpected drug-related SAEs that require expedited reporting per FDA regulations. Now that safety parameters for limited use of MDMA in clinical settings have been established, a case can be made to further develop MDMA-assisted therapeutic interventions that could support autistic adults in increasing social adaptability among the typically developing population. As in the case with classic hallucinogens and other psychedelic drugs, MDMA catalyzes shifts toward openness and introspection that do not require ongoing administration to achieve lasting benefits. This infrequent dosing mitigates adverse event frequency and improves the risk/benefit ratio of MDMA, which may provide a significant advantage over medications that require daily dosing. Consequently, clinicians could employ new treatment models for social anxiety or similar types of distress administering MDMA on one to several occasions within the context of a supportive and integrative psychotherapy protocol.

Argon blocks the expression of locomotor sensitization to amphetamine through antagonism at the vesicular monoamine transporter-2 and mu-opioid receptor in the nucleus accumbens

We investigated the effects of the noble gas argon on the expression of locomotor sensitization to amphetamine and amphetamine-induced changes in dopamine release and mu-opioid neurotransmission in the nucleus accumbens. We found (1) argon blocked the increase in carrier-mediated dopamine release induced by amphetamine in brain slices, but, in contrast, potentiated the decrease in KCl-evoked dopamine release induced by amphetamine, thereby suggesting that argon inhibited the vesicular monoamine transporter-2; (2) argon blocked the expression of locomotor and mu-opioid neurotransmission sensitization induced by repeated amphetamine administration in a short-term model of sensitization in rats; (3) argon decreased the maximal number of binding sites and increased the dissociation constant of mu-receptors in membrane preparations, thereby indicating that argon is a mu-receptor antagonist; (4) argon blocked the expression of locomotor sensitization and context-dependent locomotor activity induced by repeated administration of amphetamine in a long-term model of sensitization. Taken together, these data indicate that argon could be of potential interest for treating drug addiction and dependence.

Case report of ecstasy-induced renal venous thrombosis

The use of 3,4-methylenedioxymethamphetamine, also known as MDMA or ecstasy, has been associated with vascular and end-organ damage. This case report describes, with histological evidence, the development renal venous thrombosis presenting with acute kidney injury following oral ingestion of 3,4-methylenedioxymethamphetamine (ecstasy).

The agony of ecstasy: MDMA (3,4-methylenedioxymethamphetamine) and the kidney

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.

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.

Effets aigus et à long terme de l’ecstasy

Side effects in the short term Recreational use of Ecstasy (3,4-methylenedioxymethamphetamine or MDMA), a synthetic drug, has considerably increased over the last decade. Since its appearance it is associated with the rave culture, but its use has spread to other social settings. The drug produces euphoria and empathy, but can lead to side effects, notably acute, potentially lethal, toxicity (malignant hyperthermia and/or hepatitis). Neurotoxicity in the long-term Moreover, MDMA has been shown to induce long-term deleterious effects and provoke neurotoxic affecting the serotoninergic system. However, the psychopathological consequences of such neurotoxicity are still controversial, particularly since many ecstasy consumers are multi-drug users. A complex pharmacological profile The mechanism of action of MDMA involves various neurobiological systems (serotonin, dopamine, noradrenalin), that may all interact.

Ecstasy-induced brain death and acute hepatocellular failure: multiorgan donor and liver transplantation

BACKGROUND

Ecstasy is a neurotoxic and hepatotoxic drug. Brain edema and fulminant hepatic failure are two of the most serious complications associated with the consumption of ecstasy. Acute ecstasy intoxication can transform a patient into an organ donor or a hepatic graft recipient.

MATERIALS AND METHODS

In the last 5 years in our centers, we have had two multiorgan donors who died from ecstasy-induced brain edema and three patients who required urgent orthotopic liver transplantation for treatment of severe acute hepatocellular failure induced by this drug. We performed eight transplantations using the organs of these two brain-dead donors: one heart, one bipulmonary, three kidneys, one kidney-pancreas, and two livers.

RESULTS

Toxicity caused by ecstasy was not observed in any of the eight patients who underwent transplantation. The clinical state and the graft function of the heart, two liver, renopancreatic, and three kidney recipients were normal for a follow-up period that ranged between 7 months and 4.5 years. The lung recipient died from multiorgan failure secondary to bilateral pneumonia 5 days after the transplantation, and one of the kidney transplant patients died as a result of intestinal lymphoma 6 months after transplantation. The three liver transplantations in the three patients with ecstasy-induced fulminant hepatic failure were performed successfully using orthotopic transplantation. These three recipients are asymptomatic and have normal-functioning hepatic grafts after follow-up of 3.5 years, 15 months, and 11 months, respectively.

CONCLUSIONS

The thoracic and abdominal organs of people dying from ecstasy intoxication can be viable for transplantation. The short- and medium-term survival of the graft and of the recipient have been similar to that of other organ donors. Urgent liver transplantation is an effective therapeutic option in patients with ecstasy-induced acute hepatocellular failure.

The pharmacology and toxicology of "ecstasy" (MDMA) and related drugs

"Ecstasy" (MDMA) and related drugs are amphetamine derivatives that also have some of the pharmacological properties of mescaline. They have become popular with participants in "raves," because they enhance energy, endurance, sociability and sexual arousal. This vogue among teenagers and young adults, together with the widespread belief that "ecstasy" is a safe drug, has led to a thriving illicit traffic in it. But these drugs also have serious toxic effects, both acute and chronic, that resemble those previously seen with other amphetamines and are caused by an excess of the same sympathomimetic actions for which the drugs are valued by the users. Neurotoxicity to the serotonergic system in the brain can also cause permanent physical and psychiatric problems. A detailed review of the literature has revealed over 87 "ecstasy"-related fatalities, caused by hyperpyrexia, rhabdomyolysis, intravascular coagulopathy, hepatic necrosis, cardiac arrhythmias, cerebrovascular accidents, and drug-related accidents or suicide. The toxic or even fatal dose range overlaps the range of recreational dosage. The available evidence does not yet permit an accurate assessment of the size of the problem presented by the use of these drugs.

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.

Aortic dissection after ingestion of "ecstasy" (MDMA)

The authors report a case of aortic dissection and cardiac tamponade in a 29-year-old man after ingestion of ecstasy (methylenedioxymethamphetamine, MDMA) at a "rave" party. There was no history of hypertension, myxoid heart disease, or other risk factors for aortic dissection in the deceased, although a minor degree of cystic medial necrosis was noted on histologic examination of the aorta. Autopsy toxicology revealed low residual levels of MDMA in the blood about 48 hours after ingestion of the drug. This case report describes a probable association between MDMA ingestion and aortic dissection in a previously well young adult. The likely mechanisms are discussed, and the difficulties in diagnosing this complication are highlighted.

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.

Neuropsychiatric manifestations following the use of 3,4-methylenedioxymethamphetamine (MDMA: "Ecstasy")

1. The recurring side-effects associated with MDMA consumption are reviewed. 2. The recreational use of "Ecstasy" has been implicated in the onset of various psychological, neurological, and organic complications. A table has been employed to depict the deleterious reactions that have occurred following MDMA ingestion. 3. An original case report is presented in which an individual developed perpetual neuropsychiatric symptomatology after having consumed MDMA. This case indicates that MDMA may induce long lasting effects, even after one exposure.

Adverse reactions with 3,4-methylenedioxymethamphetamine (MDMA; 'ecstasy')

3,4-Methylenedioxymethamphetamine (MDMA; 'ecstasy') is an increasingly popular recreational drug in the US, Western Europe and Australia. In animals, including nonhuman primates, MDMA is known to damage brain serotonin (5-hydroxytryptamine; 5-HT) neurons. It is not known whether MDMA damages serotonin neurons in the human brain but there is some indication that it may. Although the large majority of individuals who have used MDMA recreationally do not develop acute complications, as the popularity of MDMA has increased, so have reports of adverse nonpsychiatric and psychiatric consequences associated with use of the drug. Further, since manifestations of MDMA-induced serotonin injury might only become apparent with age, or under periods of stress, it is possible that some individuals with no apparent abnormalities might develop complications over time.

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.