Ten years of 'ecstasy'

Postmortem diagnosis of hyponatremia: case report and literature review

Hyponatremia is defined as a plasma sodium concentration less than 135 or 130 mEq/L (or mmol/L) and may be responsible for life threatening symptoms that can be observed in a variety of medical conditions. Cases of fatal hyponatremia have been reported in both clinical and forensic literature in situations of water intoxication due to psychogenic polydipsia, amphetamine derivative drug intake, high-endurance exercise, iatrogenic causes, and exceptional cases of child abuse by forced water intoxication. Vitreous sodium levels have been determined to be relatively stable during the early postmortem period and similar to levels found in normal serum of living subjects. Nevertheless, there are relatively few cases of fatal hyponatremia described in literature that underwent exhaustive postmortem biochemical investigations. A case of fatal water intoxication in a psychiatric patient who underwent medicolegal investigations, including postmortem biochemistry, was chosen as a starting point to a literature review of deaths by hyponatremia that may be encountered in the forensic setting.

When plenty is too much: water intoxication in a patient with a simple urinary tract infection

Healthcare professionals frequently advise patients with simple infective illness to drink more fluids. Here, a 59-year-old woman with a urinary tract infection followed such advice resulting in hospital admission with symptomatic acute hyponatraemia. Water intoxication is well recognised as a cause of symptomatic hyponatraemia in endurance sports, MDMA use and psychogenic polydipsia. It has rarely been described outside of these circumstances. With normal renal function, it is difficult to overwhelm the excretory capacity for water. However, in infective illness, increased levels of antidiuretic hormones (which may be secreted both appropriately to correct volume status and inappropriately as a feature of disease) reduce renal excretion of water. In this scenario, could increased administration of oral hypotonic fluids lead to hyponatraemia, with associated morbidity and mortality, than has previously been recognised? There is a need for more research to qualify our oft-given advise to drink more fluids.

San Francisco's Freelancing Ecstasy Dealers: Towards a Sociological Understanding of Drug Markets

We present analyses based on selected findings from a NIDA-funded project entitled, “An Exploratory Study of Ecstasy Distribution” (2003–2006). We conducted in-depth interviews with 120 men and women in the San Francisco Bay area who had sold five or more doses five or more times in the six months prior to the interview. The research focused on the motivations and circumstances surrounding the decision to initiate sales, sales settings, the characteristics of both sellers and buyers and their relationships. It also focused on negotiated order and social identities. We describe the ways in which a sample of educated, housed, and employed Ecstasy dealers' attitudes and practices compared with more marginalized groups from other drug market studies. These findings suggest attention to social class, that is, the social characteristics of sellers and the availability of types of sales settings (public vs. private) is critical to developing a sociological understanding of drug markets.

The “Bath Salt” Mephedrone - A New(ish) Kid on the Block

There have been increasing reports in the popular and scientific media of the use of drugs called “Bath Salts”. These drugs have nothing to do with ordinary bath salts but are synthetic ring substituted cathinones. The main drugs encountered are mephedrone, methylone and 3,4-methylenedioxypyrovalerone (MDPV). Most reports involve the drug mephedrone, which has been popular in Europe but “Bath Salt” cases are also seen in North America. These drugs have sympathomimetic effects and the reported deaths have had similar histories to other stimulant drugs. This review examines the use of “Bath Salts”, particularly mephedrone and its clinical effects and toxicology, along with reported autopsy findings.

Forensic aspects of water intoxication: four case reports and review of relevant literature

Water intoxication (WI) is a rare condition that originates from over-consumption of water, with a potentially fatal outcome. Increased water intake (polydipsia) is followed by urination of high amount of diluted urine (polyuria) which are the main initial symptoms of WI. We present four case reports of WI. Two of them are unusual pediatric clinical cases using medical documentation and police case files, one of which is related to child abuse, and the other to a psychiatric disorder. The other two cases are fatal adult cases submitted to autopsy from a psychiatric hospital. Also, we present a diagnostic algorithm for polydipsia and polyuria before death. WI is usually seen in patients with psychiatric disorders, victims of child abuse or torture, drug abusers or it can be iatrogenically induced.

[Anesthesia in drug addiction]

The growing social problem of drug abuse has increased the likelihood that anesthesiologists will find acute or chronic drug users among patients requiring anesthesia for elective or emergency surgery. We must therefore be aware of the effects drugs have on the organism and their possible pharmacokinetic and pharmacodynamic interactions with anesthetic agents in order to prevent complications during surgery and postoperative recovery. Such knowledge is required for the management of abstinence syndrome or overdose, which pose the greatest potential dangers for the hospitalized drug addict.

What's in a label? Ecstasy sellers' perceptions of pill brands

This article presents selected findings from a qualitative study of Ecstasy sellers and their sales practices, knowledge of distribution networks, buyer-seller relationships, and self-reported drug use. In-depth interviews were conducted with 80 men and women who had sold five or more hits of Ecstasy five or more times in the six months prior to the interview. Study participants described their perceptions of the various types of Ecstasy they had distributed or used themselves. The participants had experience with a variety of Ecstasy labels, from the popular "Blue Dolphin" tablets to the powdered form called "Molly." We tracked pill brand mentions on Ecstasy-related websites to compare with interviewees' descriptions of Ecstasy brands. This study examines Ecstasy sellers' ideas about the role of brand names in Ecstasy markets and their relationship to their beliefs about different types of Ecstasy's purity and quality. We demonstrate that considering Ecstasy branding increases our understanding of buyer and seller relationships.

Morbidity in a population of low-income, female users of MDMA and other drugs

Few previous studies have reported on the overall health of drug-using women. To investigate this, 696 low-income women aged 18-31 were recruited in a cross-sectional study from gynecological care clinics in Texas between 2001 and 2003. Compared to exclusive marijuana users and non-drug users, women who used MDMA and those who used other illicit drugs but not MDMA reported more gynecological conditions, medical conditions, depressive symptoms, and physical somatic complaints. We concluded that young, low-income women who used more than one illicit drug experience significantly more physical and psychological morbidity. Generalization of this study results may be limited to young women with low income but not to other populations.

Pharmacology of stimulants prohibited by the World Anti-Doping Agency (WADA)

This review examines the pharmacology of stimulants prohibited by the World Anti-Doping Agency (WADA). Stimulants that increase alertness/reduce fatigue or activate the cardiovascular system can include drugs like ephedrine available in many over-the-counter medicines. Others such as amphetamines, cocaine and hallucinogenic drugs, available on prescription or illegally, can modify mood. A total of 62 stimulants (61 chemical entities) are listed in the WADA List, prohibited in competition. Athletes may have stimulants in their body for one of three main reasons: inadvertent consumption in a propriety medicine; deliberate consumption for misuse as a recreational drug and deliberate consumption to enhance performance. The majority of stimulants on the list act on the monoaminergic systems: adrenergic (sympathetic, transmitter noradrenaline), dopaminergic (transmitter dopamine) and serotonergic (transmitter serotonin, 5-HT). Sympathomimetic describes agents, which mimic sympathetic responses, and dopaminomimetic and serotoninomimetic can be used to describe actions on the dopamine and serotonin systems. However, many agents act to mimic more than one of these monoamines, so that a collective term of monoaminomimetic may be useful. Monoaminomimietic actions of stimulants can include blockade of re-uptake of neurotransmitter, indirect release of neurotransmitter, direct activation of monoaminergic receptors. Many of the stimulants are amphetamines or amphetamine derivatives, including agents with abuse potential as recreational drugs. A number of agents are metabolized to amphetamine or metamphetamine. In addition to the monoaminomimetic agents, a small number of agents with different modes of action are on the list. A number of commonly used stimulants are not considered as Prohibited Substances.

Ecstasy ingestion causing heatstroke-like, multiorgan injury in a toddler

3,4-Methylenedioxymethamphetamine (MDMA) ingestion can cause febrile status epilepticus in children but has not been reported to cause multiorgan dysfunction seen in young adults. We describe a toddler who was diagnosed at this stage of multiorgan injury. This drug, a synthetic amphetamine, has the "street" name of "ecstasy" and is commonly used by teenagers and young adults to augment the euphoric experience of "raves."

Methods to produce hyperthermia-induced brain dysfunction

The recent increase in the frequency and intensity of killer heat waves across the globe has aroused worldwide medical attention to exploring therapeutic strategies to attenuate heat-related morbidity and/or mortality. Death due to heat-related illnesses often exceeds >50% of heat victims. Those who survive are crippled with lifetime disabilities and exhibit profound cognitive, sensory, and motor dysfunction akin to premature neurodegeneration. Although more than 50% of the world populations are exposed to summer heat waves; our understanding of detailed underlying mechanisms and the suitable therapeutic strategies have still not been worked out. One of the basic reasons behind this is the lack of a reliable experimental model to simulate clinical hyperthermia. This chapter describes a suitable animal model to induce hyperthermia in rats (or mice) comparable to the clinical situation. The model appears to be useful for studying the effects of heat-related illnesses on changes in various organs and systems, including the central nervous system (CNS). Since hyperthermia is often associated with profound brain dysfunction, additional methods to examine some crucial parameters of brain injury, e.g., blood-brain barrier (BBB) breakdown and brain edema formation, are also described.

The impact of alcohol, tobacco, and other drug use and abuse in the emergency department

Alcohol, tobacco, and other drug use is a significant societal problem. Individuals who use these substances are frequently seen in emergency departments at rates disproportionately greater than their population prevalence. This article highlights the impact of these drugs on patients and on emergency departments, including common presenting problems of individuals on these substances. Also discussed is how to help and to refer individuals with substance abuse problems through brief motivational interventions.

A profile of Ecstasy (MDMA) use in São Paulo, Brazil: an ethnographic study

The use of Ecstasy in Brazil has gained visibility in recent years. Nevertheless, scientific data on this issue remain scarce. The present study focused on clarifying this phenomenon by means of qualitative and ethnographic research. Observational studies (N = 8), information obtained from key informants (N = 14) and interviews with Ecstasy users (N = 32) from the city of São Paulo were part of this study. The results pointed to night clubs and rave parties where electronic music is played as the main context of use. Interviews with users revealed a sample of young adult members of the highest layers of society, with a good educational background and access to the labor market. Furthermore, polydrug use was manifested. Users' typology was established regarding the pattern of drug use, showing two profiles of users: the "Rave Generation," consisting of more recent users who initiated this use with the arrival of the large-sized rave parties at the end of the 1990s. The second profile, the "Sons of the Hell's Club," consisted of more experienced users (beginning in the early 1990s) and showed a richer history of use. Neither profile group had sought help regarding their Ecstasy use, and both showed positive beliefs related to the safety of use.

Club drug use among delinquent youth

The availability and use of club drugs have increased in the last decade. Media and researchers have responded with increased coverage and a variety of studies. Despite the increased attention, some of these drugs and the rave/club scene in which they seemingly gained popularity are relatively new. Questions remain about the people who use club drugs, how best to go about preventing or dealing with the use of these substances, and the social contexts, subcultures, and manner in which club drugs are used. Complicating matters, the use and users of club drugs seem to be continually evolving. Club drugs are reportedly now available and used in a wide variety of locations, and the users are changing demographically. Members of racial/ethnic groups who previously avoided club drugs are beginning to use these substances, and the average age of onset appears to be decreasing. Additional research on the epidemiology of club drug use among samples that are demographically and geographically diverse is needed. This study is an analysis of factors associated with several measures of club drug use among a sample of delinquent youth in Oregon. Descriptive, bivariate, and multivariate analyses are used to identify factors associated with club drug use and determine whether the current grouping of club drugs is appropriate. Findings indicate that users of club drugs are significantly different from delinquent youth who have not used club drugs on a number of dimensions, including age, engagement in risk behaviors, victimization, home environment, and rave attendance.

Clozapine reverses hyperthermia and sympathetically mediated cutaneous vasoconstriction induced by 3,4-methylenedioxymethamphetamine (ecstasy) in rabbits and rats

Life-threatening hyperthermia occurs in some individuals taking 3,4-methylenedioxymethamphetamine (MDMA, ecstasy). In rabbits, sympathetically mediated vasoconstriction in heat-exchanging cutaneous beds (ear pinnae) contributes to MDMA-elicited hyperthermia. We investigated whether MDMA-elicited cutaneous vasoconstriction and hyperthermia are reversed by clozapine and olanzapine, atypical antipsychotic agents. Ear pinna blood flow and body temperature were measured in conscious rabbits; MDMA (6 mg/kg, i.v.) was administered; and clozapine (0.1-5 mg/kg, i.v.) or olanzapine (0.5 mg/kg, i.v.) was administered 15 min later. One hour after MDMA, temperature was 38.7 +/- 0.5 degrees C in 5 mg/kg clozapine-treated rabbits and 39.0 +/- 0.2 degrees C in olanzapine-treated rabbits, less than untreated animals (41.5 +/- 0.3 degrees C) and unchanged from pre-MDMA values. Ear pinna blood flow increased from the MDMA-induced near zero level within 5 min of clozapine or olanzapine administration. Clozapine-induced temperature and flow responses were dose-dependent. In urethane-anesthetized rabbits, MDMA (6 mg/kg, i.v.) increased ear pinna postganglionic sympathetic nerve discharge to 217 +/- 33% of the pre-MDMA baseline. Five minutes after clozapine (1 mg/kg, i.v.) discharge was reduced to 10 +/- 4% of the MDMA-elicited level. In conscious rats made hyperthermic by MDMA (10 mg/kg, s.c.), body temperature 1 hr after clozapine (3 mg/kg, s.c.) was 36.9 +/- 0.5 degrees C, <38.6 +/- 0.3 degrees C (Ringer's solution-treated) and not different from the pre-MDMA level. One hour after clozapine, rat tail blood flow was 24 +/- 3 cm/sec, greater than both flow in Ringer's solution-treated rats (8 +/- 1 cm/sec) and the pre-MDMA level (17 +/- 1 cm/sec). Clozapine and olanzapine, by interactions with 5-HT receptors or by other mechanisms, could reverse potentially fatal hyperthermia and cutaneous vasoconstriction occurring in some humans after ingestion of MDMA.

Clozapine reverses hyperthermia and sympathetically mediated cutaneous vasoconstriction induced by 3,4-methylenedioxymethamphetamine (ecstasy) in rabbits and rats

Life-threatening hyperthermia occurs in some individuals taking 3,4-methylenedioxymethamphetamine (MDMA, ecstasy). In rabbits, sympathetically mediated vasoconstriction in heat-exchanging cutaneous beds (ear pinnae) contributes to MDMA-elicited hyperthermia. We investigated whether MDMA-elicited cutaneous vasoconstriction and hyperthermia are reversed by clozapine and olanzapine, atypical antipsychotic agents. Ear pinna blood flow and body temperature were measured in conscious rabbits; MDMA (6 mg/kg, i.v.) was administered; and clozapine (0.1-5 mg/kg, i.v.) or olanzapine (0.5 mg/kg, i.v.) was administered 15 min later. One hour after MDMA, temperature was 38.7 +/- 0.5 degrees C in 5 mg/kg clozapine-treated rabbits and 39.0 +/- 0.2 degrees C in olanzapine-treated rabbits, less than untreated animals (41.5 +/- 0.3 degrees C) and unchanged from pre-MDMA values. Ear pinna blood flow increased from the MDMA-induced near zero level within 5 min of clozapine or olanzapine administration. Clozapine-induced temperature and flow responses were dose-dependent. In urethane-anesthetized rabbits, MDMA (6 mg/kg, i.v.) increased ear pinna postganglionic sympathetic nerve discharge to 217 +/- 33% of the pre-MDMA baseline. Five minutes after clozapine (1 mg/kg, i.v.) discharge was reduced to 10 +/- 4% of the MDMA-elicited level. In conscious rats made hyperthermic by MDMA (10 mg/kg, s.c.), body temperature 1 hr after clozapine (3 mg/kg, s.c.) was 36.9 +/- 0.5 degrees C, <38.6 +/- 0.3 degrees C (Ringer's solution-treated) and not different from the pre-MDMA level. One hour after clozapine, rat tail blood flow was 24 +/- 3 cm/sec, greater than both flow in Ringer's solution-treated rats (8 +/- 1 cm/sec) and the pre-MDMA level (17 +/- 1 cm/sec). Clozapine and olanzapine, by interactions with 5-HT receptors or by other mechanisms, could reverse potentially fatal hyperthermia and cutaneous vasoconstriction occurring in some humans after ingestion of MDMA.

5-hydroxytryptamine(2A) receptors regulate sympathetic nerves constricting the cutaneous vascular bed in rabbits and rats

Hyperthermia induced by 3,4-methylenedioxymethamphetamine (MDMA) is partially due to sympathetically-mediated cutaneous vasoconstriction that impairs normal heat dissipation. MDMA acts by releasing monoamines, including 5-hydroxytryptamine (5-HT), but receptor mechanisms underlying MDMA-elicited hyperthermia and cutaneous vasoconstriction are not known. The specific 5-HT2A agonist (+/-)-1-(2,5-dimethoxy-4-iodophenyl)-2-aminopropane (DOI) is a potent hallucinogen that also causes marked hyperthermia, suggesting the possibility that DOI, via stimulation of 5-HT2A receptors, might also cause sympathetically mediated cutaneous vasoconstriction. We tested this hypothesis in conscious unrestrained rabbits and rats. Blood flow was assessed by chronically implanted Doppler ultrasonic flow probes. Body temperature was measured by i.p. telemetric probes. We compared effects of DOI on cutaneous blood flow (ear pinna in rabbits, tail in rats) with effects on mesenteric blood flow and arterial pressure.Hyperthermia induced by DOI (5-100 microgram/kg i.v. in rabbits and 100 microgram/kg s.c. in rats) was preceded and accompanied by markedly reduced blood flow to the cutaneous bed, with no change in flow to the mesenteric bed. In rabbits, DOI (5 microgram/kg i.v.) did not affect arterial pressure or heart rate. DOI (100 microgram/kg i.v.) caused a moderate rise in arterial pressure. In rabbits, the 5-HT2A receptor antagonists ketanserin (0.3 mg/kg i.v.) and AC90179 (0.5 mg/kg i.v.) reversed the ear pinna vasoconstriction induced by DOI (5 microgram/kg i.v.). In rats, ketanserin (3 mg/kg s.c.) reversed tail vasoconstriction and hyperthermia induced by DOI (100 microgram/kg s.c.). In rabbits, the cutaneous vasoconstricting effect of DOI (5 microgram/kg i.v.) was substantially abolished in the ipsilateral ear pinna after interruption of preganglionic sympathetic nerve activity by unilateral section of the cervical sympathetic trunk. Thus hyperthermia evoked by direct stimulation of 5-HT2A receptors is associated with marked sympathetically mediated vasoconstriction, selective for the cutaneous bed. Impairment of the ability to dissipate heat following drug-induced stimulation of 5-HT2A receptors is likely to contribute to hyperthermia induced by MDMA and by hallucinogenic drugs such as LSD.

Comparative effects of substituted amphetamines (PMA, MDMA, and METH) on monoamines in rat caudate: a microdialysis study

Paramethoxyamphetamine (PMA) is a methoxylated phenethylamine derivative that has been used illicitly in Australia since 1994. PMA is also becoming popular at rave parties in the United States. PMA raised concern when a series of fatalities resulted after its use in South Australia, where it was marketed as "ecstasy," which is the colloquial name for MDMA. In the present study, we evaluated the comparative neurotoxicity of substituted amphetamines in rats. Extracellular levels of dopamine (DA), 3,4-dihydroxyphenylacetic acid (DOPAC), homovanillic acid (HVA), serotonin (5-HT), and 5-hydroxyindoleacetic acid (5-HIAA) were assayed in the caudate of freely moving rats using microdialysis and HPLC-EC. Dialysates were assayed every 20 minutes for 4 hours after an intraperitoneal (i.p.) injection of PMA (2.5, 5, 10, 20 mg/kg), MDMA (10 and 20 mg/kg), or METH (2.5 mg/kg). METH produced a significant increase in extracellular DA (700%), and significant decreases in extracellular DOPAC and HVA (30% and 50%), with no detectable changes in either 5-HT or 5-HIAA. MDMA produced significant increases in DA (700% at 10 mg/kg and 950% at 20 mg/kg) and decreases in DOPAC (15% for both 10 and 20 mg/kg), and HVA (50% at 10 mg/kg and 35% at 20 mg/kg). MDMA also increased 5-HT (350% at 10, and 575% at 20 mg/kg), and decreased 5-HIAA to 60% for both dose levels. PMA produced no detectable increases in DA at dose levels of 2.5, 5, or 10 mg/kg, but significantly increased DA (975%) at a dose of 20 mg/kg. However, PMA significantly decreased DOPAC at all dose levels (75% at 2.5; 40% at 5; 30% at 10; 10% at 20 mg/kg), with comparable decreases in HVA at all dose levels. PMA also produced significant increases in 5-HT at 10 and 20 mg/kg (350% for both dose levels), with no detectable changes in 5-HT at 2.5 or 5 mg/kg. All dose levels of PMA significantly decreased 5-HIAA (50 to 70%). These data suggest that PMA, like MDMA and METH, is capable of producing dopaminergic and serotonergic neurotoxicity.

MDMA ('ecstasy') and other 'club drugs'. The new epidemic

Unfortunately, perceptions that the club drugs can be safe endure. Some groups, such as the Multidisciplinary Association for Psychedelic Study, continue to lobby for the legalization of MDMA for research purposes [76]. DanceSafe is an organization that seeks to educate the "nonaddicted" user to decrease the risks [82]. The DanceSafe Web site offers tips on the safe use of MDMA, such as attention to hydration status and ambient temperature. It also offers free testing of tablets submitted by mail and sells home testing kits to determine the content of pills sold as "ecstasy." Although much remains unknown about the long-term consequences of MDMA and the club drugs, there are clearly enough short-term dangers to prompt more aggressive education and surveillance for its use. Scare tactics and exaggerations often are ignored [53], while Web sites full of anecdotal or incomplete information may lead the unaware user to increased use [113]. Organizations such as DanceSafe imply that proper education decreases addiction and that only uneducated users or addicts suffer the life-altering consequences of drug use. The fallacy in the mission of educating "nonaddicted" users is evident. Peer-based education, with a focus on both he short-term dangers and long-term consequences, may be a more effective approach [9]. Both new and established drugs of abuse continue to plague teens and young adults. Pediatric, family practice, and Med-Peds physicians, and pediatric pharmacologists need to remain vigilant about patterns and trends of drug abuse. MDMA and the other "club drugs" are not benign. Their effects target the brain, alter neurochemistry, and possibly cause irreversible structural damage. What may seem like a harmless drug in a weekend dance club has the potential for major public health problems in years to come [109]. Effective education and timely intervention may prevent these addictive drugs from becoming a way of life, a lifestyle that may have a literal "dead end."

Cutaneous vasoconstriction contributes to hyperthermia induced by 3,4-methylenedioxymethamphetamine (ecstasy) in conscious rabbits

3,4-Methylenedioxymethamphetamine (MDMA; "Ecstasy") increases body temperature. This process could be associated with increased cutaneous blood flow, as normally occurs with exercise-induced hyperthermia. Alternatively, an MDMA-induced fall in cutaneous blood flow could contribute to the hyperthermia by diminishing normal heat transfer from the body to the environment. We investigated these possibilities by administering MDMA (1.5-6 mg/kg, i.v.) to conscious freely moving rabbits, determining effects on body temperature, cutaneous blood flow (measured by a Doppler ultrasonic probe that was chronically implanted around the ear pinna artery), and other cardiovascular parameters. MDMA caused a dose-dependent increase in body temperature (from 38.3 +/- 0.3 to 41.2 +/- 0.4 degrees C after 6 mg/kg; p < 0.01; n = 5), preceded and accompanied by a dose-dependent cutaneous vasoconstriction (from 29 +/- 6 to 5 +/- 1 cm/sec after 6 mg/kg; p < 0.01; n = 5). MDMA (3 mg/kg) did not change blood flow to the mesenteric vascular bed. Prior unilateral cervical sympathectomy reduced the increase in body temperature elicited by MDMA (6 mg/kg) from 2.0 +/- 0.2 to 1.3 +/- 0.2 degrees C (p < 0.01; n = 5). On the denervated side, ear pinna blood flow after MDMA injection was 13 +/- 3 cm/sec, compared with 3 +/- 1 cm/sec on the sympathetically intact side (p < 0.05; n = 5). Thus, sympathetically mediated cutaneous vasoconstriction is one mechanism whereby MDMA causes hyperthermia. Reversal of cutaneous vasoconstriction by appropriate pharmacological means could be of therapeutic benefit in humans suffering from life-threatening hyperthermia induced by MDMA.

Cutaneous vasoconstriction contributes to hyperthermia induced by 3,4-methylenedioxymethamphetamine (ecstasy) in conscious rabbits

3,4-Methylenedioxymethamphetamine (MDMA; "Ecstasy") increases body temperature. This process could be associated with increased cutaneous blood flow, as normally occurs with exercise-induced hyperthermia. Alternatively, an MDMA-induced fall in cutaneous blood flow could contribute to the hyperthermia by diminishing normal heat transfer from the body to the environment. We investigated these possibilities by administering MDMA (1.5-6 mg/kg, i.v.) to conscious freely moving rabbits, determining effects on body temperature, cutaneous blood flow (measured by a Doppler ultrasonic probe that was chronically implanted around the ear pinna artery), and other cardiovascular parameters. MDMA caused a dose-dependent increase in body temperature (from 38.3 +/- 0.3 to 41.2 +/- 0.4 degrees C after 6 mg/kg; p < 0.01; n = 5), preceded and accompanied by a dose-dependent cutaneous vasoconstriction (from 29 +/- 6 to 5 +/- 1 cm/sec after 6 mg/kg; p < 0.01; n = 5). MDMA (3 mg/kg) did not change blood flow to the mesenteric vascular bed. Prior unilateral cervical sympathectomy reduced the increase in body temperature elicited by MDMA (6 mg/kg) from 2.0 +/- 0.2 to 1.3 +/- 0.2 degrees C (p < 0.01; n = 5). On the denervated side, ear pinna blood flow after MDMA injection was 13 +/- 3 cm/sec, compared with 3 +/- 1 cm/sec on the sympathetically intact side (p < 0.05; n = 5). Thus, sympathetically mediated cutaneous vasoconstriction is one mechanism whereby MDMA causes hyperthermia. Reversal of cutaneous vasoconstriction by appropriate pharmacological means could be of therapeutic benefit in humans suffering from life-threatening hyperthermia induced by MDMA.

An exploration of the history and controversies surrounding MDMA and MDA

In existence for nearly a century, 3,4-methylenedioxyamphetamine (MDA) and 3,4-methylenedioxymethamphetamine (MDMA, "Ecstasy") have gained quite a reputation. Perceived by some as dangerous neurotoxins, and by others as potential psychotherapeutics, these compounds have become a center of controversy among academics and law enforcement officials, and in the process have gained extensive media exposure. The classification of these drugs as illicit, controlled substances in the United States has not prevented their use, and MDMA, or Ecstasy, is currently one of the most popular substances used recreationally in North America. The scheduling of MDMA and MDA has, however, led to the distribution of contaminated, or falsely represented, Ecstasy tablets, and prevented responsible research into the detrimental and therapeutic effects of these drugs. A look at the history of these compounds suggests that they have the potential to be used safely as psychotherapeutic tools, and that the legal status of MDMA and MDA may be worth reconsidering.

Poisoning with the recreational drug paramethoxyamphetamine ("death")

OBJECTIVE

To describe the clinical features of paramethoxyamphetamine (PMA; "death") poisoning and to compare these with those of people with self-reported "ecstasy" poisoning.

DESIGN

Retrospective casenote review.

PARTICIPANTS AND SETTING

22 patients who presented to the Emergency Department of the Royal Adelaide Hospital (RAH), a major metropolitan teaching hospital, between 1 January 1996 and 31 December 1998 with PMA poisoning identified through urine drug screens; and 61 patients with self-reported ecstasy poisoning between 1 September 1997 and 31 December 1998 found through the hospital databases.

RESULTS

Patients with PMA poisoning presented with tachycardia (64%), hyperthermia (temperature > 37.5 degrees C; 36%), coma (41%), seizures (32%), arrhythmias (23%), and QRS intervals > or = 100 ms (50%) with greater frequency and often greater severity than those with self-reported ecstasy poisoning. Two patients with PMA poisoning presented with severe hypoglycaemia (blood glucose level, < 1.5 mmol/L) accompanied by hyperkalaemia (K+ concentration, > 7.5 mmol/L).

CONCLUSIONS

At our hospital, PMA poisonings accounted for most of the severe reactions among people who believed they had taken ecstasy. Hypoglycaemia and hyperkalaemia may be specific to PMA poisoning. PMA toxicity should be suspected with severe or atypical reactions to "ecstasy", and confirmed by chromatographic urine drug screens.

Alcohol and substance abuse

Substance abuse and dependence is a public health problem with far-reaching societal implications. The acute toxicity of substances of abuse and medical consequences of chronic use are substantial. On a more optimistic note, a great deal of progress has been made in understanding and treating substance use disorders. Expanding knowledge concerning the neurobiology of substances of abuse and substance use disorders has led to a growth in pharmacotherapeutic treatment options. A growth in understanding of behavioral processes, motivational issues, and processes of behavioral change has been important in designing new and increasingly more effective psychosocial treatments. A growing body of evidence indicates that the treatment of substance use disorders can be effective, making early diagnosis and treatment or referral increasingly important.

Raves: a review of the culture, the drugs and the prevention of harm

Raves are all-night dance parties attended by large numbers of youth, sometimes in excess of 20,000. The rave scene, which is international in scope, is distinguished by clandestine venues, hypnotic electronic music and the liberal use of drugs such as ecstasy (3,4-methylenedioxymethamphetamine), GHB (gamma-hydroxybutyrate) and ketamine. Several rave-related deaths in Canada in 1999 alerted health authorities, parents and police to the health risks of rave attendance. Family physicians, emergency physicians and pediatricians should have some understanding of raves, the drugs and the health risks so they can effectively counsel and treat patients. The rave culture in Canada and the drugs commonly used at raves are reviewed, and strategies and initiatives for harm reduction are discussed.