Survival after massive ecstasy overdose

Drug-drug interactions between psychiatric medications and MDMA or psilocybin: a systematic review

RATIONALE & OBJECTIVES

 ± 3,4-Methylenedioxymethamphetamine (MDMA) and psilocybin are currently moving through the US Food and Drug Administration's phased drug development process for psychiatric treatment indications: posttraumatic stress disorder and depression, respectively. The current standard of care for these disorders involves treatment with psychiatric medications (e.g., selective serotonin reuptake inhibitors), so it will be important to understand drug-drug interactions between MDMA or psilocybin and psychiatric medications.

METHODS

In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we queried the MEDLINE database via PubMed for publications of human studies in English spanning between the first synthesis of psilocybin (1958) and December 2020. We used 163 search terms containing 22 psychiatric medication classes, 135 specific psychiatric medications, and 6 terms describing MDMA or psilocybin.

RESULTS

Forty publications were included in our systematic review: 26 reporting outcomes from randomized controlled studies with healthy adults, 3 epidemiologic studies, and 11 case reports. Publications of studies describe interactions between MDMA (N = 24) or psilocybin (N = 5) and medications from several psychiatric drug classes: adrenergic agents, antipsychotics, anxiolytics, mood stabilizers, NMDA antagonists, psychostimulants, and several classes of antidepressants. We focus our results on pharmacodynamic, physiological, and subjective outcomes of drug-drug interactions.

CONCLUSIONS

As MDMA and psilocybin continue to move through the FDA drug development process, this systematic review offers a compilation of existing research on psychiatric drug-drug interactions with MDMA or psilocybin.

Ecstasy : la deuxième vague…

La molécule de MDMA (3,4-méthylènedioxyméthamphétamine ou ecstasy) a plus de 100 ans. Sa consommation a explosé dans les années 1990, essentiellement dans un cadre « festif » ou « récréatif ». Elle a ensuite considérablement diminué au début des années 2000 et connaît actuellement un regain d’intérêt certain. Sa consommation a volontiers été considérée comme anodine avant qu’il n’apparaisse clairement qu’elle pouvait provoquer des décès, en l’absence même de « surdose ». Les mécanismes de toxicité sont multiples, complexes et imparfaitement élucidés. L’interaction avec les principaux neuromédiateurs est certaine. L’ecstasy est classée dans les produits empathogènes. Sa consommation vise à favoriser les relations sociales. De nombreux effets secondaires sont possibles. Les conditions de consommation, en ambiance confinée, avec une activité physique soutenue et prolongée favorisent la survenue des effets secondaires. Les effets secondaires bénins sont tolérés et considérés comme étant le « prix à payer » dans la recherche des effets psychogènes. En raison de son tropisme, les principales complications de la consommation d’ecstasy sont psychiatriques et neurologiques, mais aussi cardiovasculaires, respiratoires et métaboliques. Cependant, les formes graves de l’intoxication sont marquées par un tableau d’hyperthermie maligne responsable de complications multiples et pouvant conduire au décès. Tous les auteurs insistent sur la possibilité de complications, de formes graves, voire de décès après la consommation d’une dose unique de MDMA. Il n’y a pas de traitement spécifique. Le traitement symptomatique est au premier plan. Hydratation et sédation sont les clés de ce traitement.

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.

Combination effects of amphetamines under hyperthermia - the role played by oxidative stress

Rise in body temperature is a life-threatening consequence of 3,4-methylenedioxymethamphetamine (MDMA, ecstasy) abuse. We evaluated the impact of hyperthermia on the cytotoxicity of combinations of MDMA and three other amphetamines, often co-ingested. For this, Hep G2 cells were exposed to MDMA, d-amphetamine, methamphetamine and 4-methylthioamphetamine, individually or combined, at 40.5 °C. The results were compared with normothermia data (37.0 °C). Mixture additivity expectations were calculated by independent action and concentration addition (CA) models. To delineate the mechanism(s) underlying the elicited effects, a range of stress endpoints was evaluated, including quantification of reactive oxygen/nitrogen species (ROS/RNS), lipid peroxidation, reduced/oxidized glutathione (GSH/GSSG), ATP and mitochondrial membrane potential (Δψm) changes. Our data show that, in hyperthermia, amphetamines acted additively and mixture effects were accurately predicted by CA. At 40.5 °C, even slight increases in the concentrations of each drug/mixture promoted significant rises in cytotoxicity, which quickly shifted from roughly undetectable to maximal mortality. Additionally, the increase of RNS/ROS production, decrease of GSH, ATP depletion and mitochondrial impairment were exacerbated under hyperthermia. Importantly, when equieffective cytotoxic concentrations of the mixture and individual amphetamines were compared for all tested stress endpoints, mixture effects did not deviate from those elicited by individual treatments, suggesting that these amphetamines have a similar mode of action, which is not altered in combination. Concluding, our data indicate that amphetamine mixtures produce deleterious effects, even when individual drugs are combined at negligible concentrations. These effects are strongly exacerbated in hyperthermia, emphasizing the potential increased risks of ecstasy intake, especially when hyperthermia occurs concurrently with polydrug abuse.

Toxicity of amphetamines: an update

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

N-Acetylcysteine amide protects against methamphetamine-induced tissue damage in CD-1 mice

Methamphetamine (METH), a highly addictive drug used worldwide, induces oxidative stress in various animal organs, especially the brain. This study evaluated oxidative damage caused by METH to tissues in CD-1 mice and identified a therapeutic drug that could protect against METH-induced toxicity. Male CD-1 mice were pretreated with a novel thiol antioxidant, N-acetylcysteine amide (NACA, 250 mg/kg body weight) or saline. Following this, METH (10 mg/kg body weight) or saline intraperitoneal injections were administered every 2 h over an 8-h period. Animals were killed 24 h after the last exposure. NACA-treated animals exposed to METH experienced significantly lower oxidative stress in their kidneys, livers, and brains than the untreated group, as indicated by their levels of glutathione, malondialdehyde, and protein carbonyl and their catalase and glutathione peroxidase activity. This suggests that METH induces oxidative stress in various organs and that a combination of NACA as a neuro- or tissue-protective agent, in conjunction with current treatment, might effectively treat METH abusers.

Substance use and its implications for the critical care nurses: a literature review

BACKGROUND

Illicit drug use in Australia has been increasing and studies indicate that illicit drug users have a higher risk of accidents which may result in the user needing critical care. However, there is a significant gap in the literature specifically pertaining to the implications of drug use in critical care.

AIMS

The primary objective was to examine the literature for the physiological effects of methylenedioxymethamphetamine (MDMA), cocaine and amphetamines in critically ill patients.

METHODS

A comprehensive literature review was undertaken and a body systems framework was used to categorise the effects of these illicit drugs.

RESULTS

The illicit substances addressed have potentially fatal and long-term side effects. For those users involved in accidents or trauma requiring intensive or critical care nursing, the mortality and co-morbidity risks are increased significantly. It is, therefore, important that nurses are able to recognise the specific physiological effects and possible complications that can occur with the use of each illicit drug.

CONCLUSION

Both nursing and medical staff need to have a thorough understanding of how illicit substances work and how they can affect the critical care patient and the care they are given.

Caffeine promotes hyperthermia and serotonergic loss following co-administration of the substituted amphetamines, MDMA (“Ecstasy”) and MDA (“Love”)

The present study determined the effect of caffeine co-administration on the core body temperature response and long-term serotonin (5-HT) loss induced by methylenedioxymethamphetamine (MDMA; "Ecstasy") and its metabolite methylenedioxyamphetamine (MDA; "Love") to rats. In group-housed animals, caffeine (10 mg/kg) enhanced the acute toxicity of MDMA (15 mg/kg) and MDA (7.5 mg/kg), resulting in an exaggerated hyperthermic response (+2 degrees C for 5 h following MDMA and +1.5 degrees C for 3 h following MDA) when compared to MDMA (+1 degree C for 3 h) and MDA (+1 degree C for 1 h) alone. Co-administration of caffeine with MDMA or MDA was also associated with increased lethality. To reduce the risk of lethality, doses of MDMA and MDA were reduced in further experiments and the animals were housed individually. To examine the effects of repeated administration, animals received MDMA (10 mg/kg) or MDA (5 mg/kg) with or without caffeine (10 mg/kg) twice daily for 4 consecutive days. MDMA and MDA alone induced hypothermia (fall of 1 to 2 degrees C) over the 4 treatment days. Co-administration of caffeine with MDMA or MDA resulted in hyperthermia (increase of up to 2.5 degrees C) following acute administration compared to animals treated with caffeine or MDMA/MDA alone. This hyperthermic response to caffeine and MDMA was not observed with repeated administration, unlike caffeine + MDA, where hyperthermia was obtained over the 4 day treatment period. In addition, 4 weeks after the last treatment, co-administration of caffeine with MDA (but not MDMA) induced a reduction in 5-HT and 5-hydroxyindole acetic acid (5-HIAA) concentrations in frontal cortex (to 61% and 58% of control, respectively), hippocampus (48% and 60%), striatum (79% and 64%) and amygdala (63% and 37%). However, when caffeine (10 mg/kg) and MDMA (2.5 mg/kg) were co-administered four times daily for 2 days to group-housed animals, both hyperthermia and hippocampal 5-HT loss were observed (reduced to 68% of control). Neither MDMA nor MDA alone induced a significant reduction in regional 5-HT or 5-HIAA concentrations following repeated administration. In conclusion, caffeine promotes the acute and long-term toxicity associated with MDMA and MDA. This is a serious drug interaction, which could have important acute and long-term health consequences for recreational drug users.

Ecstasy—deadly risk even outside rave parties

Fatalities due to 3,4-methylenedioxymethamphetamine (MDMA, "ecstasy") are rare in Austria, although the use of designer drugs has become quite common. This is the first published case of a fatal MDMA intoxication in Austria. A 19-year-old girl died after the consumption of ecstasy tablets in the apartment of a friend. Blood analysis gave a concentration of MDMA as 3.8 mg/L and traces of its metabolite MDA. Cannabinoids were found as well. This case shows that the consumption of MDMA, without physical stress, can lead to death.

Acute toxic effects of club drugs

This article summarizes the short-term physiological toxicity and the adverse behavioral effects of four substances (GHB, ketamine, MDMA, and Rohypnol) that have been used at latenight dance clubs. The two primary data sources were case studies of human fatalities and experimental studies with laboratory animals. A safety ratio was calculated for each substance based on its estimated lethal dose and its customary recreational dose. GHB (gamma-hydroxybutyrate) appears to be the most physiologically toxic; Rohypnol (flunitrazepam) appears to be the least physiologically toxic. The single most risk-producing behavior of club drug users is combining psychoactive substances, usually involving alcohol. Hazardous drug-use sequelae such as accidents, aggressive behavior, and addiction were not factored into the safety ratio estimates.

Tissue concentrations of MDMA and its metabolite MDA in three fatal cases of overdose

The recreational use of amphetamine derivatives has become increasingly popular in our country in past recent years. Their use is especially common among young people participating in dance parties known as "raves." As a direct consequence of their increased use, the number of fatal cases in which these compounds have been involved have increased dramatically since the second half of the last decade. In our laboratory, we have registered 25 cases related to amphetamine derivatives use since 1996. Three of them were deeply studied and the results obtained are presented in this paper. This information may be useful for the interpretation of the results obtained in toxicological analysis in the cases in which death may be attributed to MDMA use.

Cyproheptadine for intrathecal baclofen withdrawal

OBJECTIVE

To evaluate the efficacy of cyproheptadine in the management of acute intrathecal baclofen (ITB) withdrawal.

DESIGN

Descriptive case series.

SETTING

University hospital with a comprehensive in- and outpatient rehabilitation center.

PARTICIPANTS

Four patients (3 with spinal cord injury, 1 with cerebral palsy) with implanted ITB infusion pumps for treatment of severe spasticity, who had ITB withdrawal syndrome because of interruption of ITB infusion.

INTERVENTIONS

Patients were treated with 4 to 8mg of cyproheptadine by mouth every 6 to 8 hours, 5 to 10mg of diazepam by mouth every 6 to 12 hours, 10 to 20mg of baclofen by mouth every 6 hours, and ITB boluses in some cases.

MAIN OUTCOME MEASURES

Clinical signs and symptoms of ITB withdrawal of varying severity were assessed by vital signs (temperature, heart rate), physical examination (reflexes, tone, clonus), and patient report of symptoms (itching, nausea, headache, malaise).

RESULTS

The patients in our series improved significantly when the serotonin antagonist cyproheptadine was added to their regimens. Fever dropped at least 1.5 degrees C, and heart rate dropped from rates of 120 to 140 to less than 100bpm. Reflexes, tone, and myoclonus also decreased. Patients reported dramatic reduction in itching after cyproheptadine. These changes were associated temporally with cyproheptadine dosing.

DISCUSSION

Acute ITB withdrawal syndrome occurs frequently in cases of malfunctioning intrathecal infusion pumps or catheters. The syndrome commonly presents with pruritus and increased muscle tone. It can progress rapidly to high fever, altered mental status, seizures, profound muscle rigidity, rhabdomyolysis, brain injury, and death. Current therapy with oral baclofen and benzodiazepines is useful but has variable success, particularly in severe cases. We note that ITB withdrawal is similar to serotonergic syndromes, such as in overdoses of selective serotonin reuptake inhibitors or the popular drug of abuse 3,4-methylenedioxymethamphetamine (Ecstasy). We postulate that ITB withdrawal may be a form of serotonergic syndrome that occurs from loss of gamma-aminobutyric acid B receptor-mediated presynaptic inhibition of serotonin.

CONCLUSION

Cyproheptadine may be a useful adjunct to baclofen and benzodiazepines in the management of acute ITB withdrawal syndrome.

Immunohistochemical study of myoglobin and oxidative injury-related markers in the kidney of methamphetamine abusers

It is known that methamphetamine (MA) causes rhabdomyolysis, myoglobinuria, and acute renal failure. We conducted an immunohistochemical study on the kidney of 22 forensic autopsy cases in which MA had been detected. Myoglobin was positive in 17 cases. The concentration of the blood MA in the myoglobin-positive cases (8.39+/-3.43 micromol/dl) was higher than -negative cases (0.198+/-0.076 micromol/dl). And, the 70 kDa heat shock protein (HSP70), 8-hydroxy-2'-deoxyguanosine (8-OH-dG), 4-hydroxy-2-nonenal (4-HNE), and Cu/Zn superoxide dismutase (SOD) were also stained positively in five, ten, 11, nine cases of examined, respectively. In addition, 80% of HSP70-positive cases were myoglobin-positive. Myoglobin was also observed in 60% of 8-OH-dG-positive, in 82% of 4-HNE-positive, and in 78% of SOD-positive cases, respectively. Therefore, myoglobin rather than MA itself might induce oxidative damage. From these results, it was considered that MA abuse had caused the skeletal muscle damage before death. In forensic autopsy cases of drug abusers, the antemortem situation is not often known. The present research suggested that in addition to the measurement of the concentration of MA, immunohistochemical staining of myoglobin, HSP70, 8-OH-dG, 4-HNE, and SOD offers important information for the diagnosis of MA poisoning.

Amphetamine derivative related deaths in northern Greece

Until 1997, only one amphetamine related derivatives (AMPs) fatality had been reported in Greece. Since then, amphetamine (AMP) or AMPs have been found in seven out of 1,500 post-mortem toxicological cases. The cause and manner of death of these seven cases were: 3,4-methylenedioxy-N-methamphetamine (MDMA) and 3,4-methylenedioxy-N-ethylamphetamine (MDEA) poisoning (n = 1), drowning in water (n = 4), cranial injuries caused by a traffic accident (n = 1) and heart failure (n = 1). In the case where the use of AMP or AMPs was considered, the immediate cause of death post-mortem toxicological analysis revealed 2 microg/ml MDMA and 0.7 microg/ml MDEA in blood. MDMA was identified in two cases of drowning (2 microg/ml in blood in the first case and 1.7 microg/g in liver in the second case) and in the traffic accident case (0.4 microg/g in liver). Methamphetamine was detected in two cases of drowning (2.5 microg/ml in blood in the first case and 6 microg/g in liver in the second case). AMP was found in the heart failure case (0.2 microg/g in liver). Alcohol was present, together with AMP or AMPs, in four cases. These findings indicate an increase in the illegal abuse of AMPs in Greece. Because of this, we now routinely screen for AMPs.

Myopathy and rhabdomyolysis with lipid-lowering drugs

Drug-induced myopathy and rhabdomyolysis are rare adverse drug reactions (ADR). They have been seen after the introduction of modern lipid-lowering drugs more regularly. The first description after medication with clofibrate dates back to 1968. Apparently, all fibrates can induce myopathy. It usually starts after a few days of medication, or after prolonged use, showing muscle weakness and/or pain. Concomitantly, the enzyme creatininephosphokinase (CPK) is raised dramatically. Muscular necrosis can follow leading secondarily to kidney failure, and eventually to death. For the class of statins, myopathy was more often seen after their introduction, and it became their most feared adverse effect, especially in combination of statins with other drugs (mibefradil, gemfibrozil, cyclosporin). In animal models the evolution of the disease and the mechanism of action may be elucidated. Though strong epidemiological data are lacking, the incidence of myopathy is probably similar for all lipid-lowering drugs and is in the range of 0.1-0.5% with monotherapy, increasing to 0.5-2.5% with combination therapy. Severe cases of rhabdomyolysis are rarer, but may have a significant mortality. The market success of cerivastatin within a short period has led to 100s of myopathies and some dozens of deaths. Though interactions on metabolism and ensuing high plasma levels can partially explain myopathy as intoxication, there are strong indications that other (endocrine, metabolic, genetic) factors might play a role in the pathophysiology. The patient population at risk should better be defined and withheld from myopathy-inducing drugs.

The many faces of ecstasy

References to the word ecstasy in popular culture can mean different things to different individuals. The most common form of ecstasy (3,4-methylenedioxymethamphetamine [MDMA]), is an amphetamine with some hallucinogenic properties at high doses. It is directly neurotoxic to the human brain and has been linked to a number of deaths worldwide. Deaths result from hyperthermia, hyponatremia, or cerebral edema. A naturally occurring metabolite of gamma-aminobutyric acid, gammahydroxybutyrate (GHB) is a potent central nervous system depressant. Although GHB is a Schedule I drug, analogs remain widely available for consumption. Acute intoxication with GHB or its analogs leads to coma and respiratory depression. Chronic use of GHB or its analogs is associated with a withdrawal syndrome characterized by autonomic excitation. Herbal ecstasy refers to ephedrine-containing preparations. Acute and chronic overdoses of herbal ecstasy have been linked to hypertension, tachydysrythmias, myocardial infarctions, cerebrovascular accidents, and deaths. There is no regulation of the ephedrine content of available herbal ecstasy products.

Myoglobinuria

Myoglobinuria refers to an abnormal pathologic state in which an excessive amount of myoglobin is found in the urine, imparting a cola-like hue, usually in association with myonecrosis and a clinical picture of weakness, myalgias, and edema. Myoglobinuria is produced by multiple causes: any condition that accelerates the use or interferes with the availability of oxygen or energy substrates to muscle cells can result in myoglobinuria, as can events that produce direct muscle injury, either mechanical or chemical. Acute renal failure is the most serious complication, which can be prevented by prompt, aggressive treatment. In patients surviving acute attacks, recovery of muscle and renal function is usually complete.