A new paper in the print queue at Drug and Alcohol Dependence presents a review of MDMA-related fatalities in Australia across a five year interval. It makes a good addition to the sort of Case by Case Report stuff that I usually talk about.
The paper is presently citable as:
Kaye, S., et al., Methylenedioxymethamphetamine (MDMA)-related fatalities in Australia: Demographics, circumstances, toxicology and major organ pathology. Drug Alcohol Depend. (2009), doi:10.1016/j.drugalcdep.2009.05.016
The authors reviewed data from the Australian National Coroners Information System from 7/1/00 - 6/30/05 and found 82 cases in which MDMA was a direct cause, an antecedent factor or a significant contributor to the death. The review divides the 67 cases of direct or antecedent cause from the 15 cases in which MDMA was a significant contributor. Death involving cardiovascular causes could list MDMA as either antecedent or a significant contributor- so there will be some degree of variance that may derive from (one assumes) individual local coroner judgment calls.
So the first thing of interest about this dataset is that 25% of direct/antecedent cause cases were attributed to MDMA alone and 66% to combined drug toxicity. The median MDMA blood levels reported were 0.85 mg/L but the range was broad, 0.03-93.0 mg/L (for reference, see prior posts on blood levels). The article takes pains to note that the median for injury / disease (0.65 mg/L) does not significantly differ from the drug-toxicity cases (still 0.85 mg/L even with the other cases taken out). For context, one of the larger reviews of MDMA-related fatalities from the US (Patel et al, 2004) found mean MDMA blood levels of about 1.7 mg/L.
Apparently paradoxically the paper goes on to indicate that 87% of blood samples had non-MDMA (and non-MDA) drugs with methamphetamine/amphetamine (50%), morphine (32%), alcohol (30%), codeine (25%) and benzodiazepines (20%) being the most common. One has to assume that the distinction between the 25% of fatalities attributed to MDMA alone over combined drug has to do with assessment of drug levels by the individual coroners.
It is sort of interesting to see the 10% attributed to cardiovascular causes because this would seemingly be a toe-hold on this question of pre-existing pathology and the interaction of the drug with a dodgy individual physiological competency. I still hold that the interaction is still an effect of the drug but it does help to see that in twice as many cases there was no suspicion of pre-existing cardiac complications. It is further interesting to observe that the extent of non-acute cardiovascular pathology in this relatively young sample (20s-30s) was higher than expected, consistent with some reports of cardiovascular abnormalities associated with MDMA exposure. Thus, some of those apparently pre-existing cardiovascular liabilities may be acquired through prior MDMA and/or other stimulant use.
One additional pertinent observation was that 62% of fatal incidents were in a private home and only 15% in a "public area"; the balance were in hospital, on the road or other. This undermines any perceptions that the rave/dance club environment is the only, or perhaps even a primary risk setting. At least, in Australia during that interval of time. I have trouble with the authors pointing to the single case in which hyperthermia was blamed as the cause of death as if this were meaningful, however. Elevated body temperature is just far too common a symptom and one wonders just what cases were listed only under MDMA or combined drug toxicity and how they differed from this single case where hyperthermia was judged the cause of death. This I would put down to local coroner interpretation of a multi-factor clinical situation.
Overall these findings are very consistent with my continued point on this topic. That first and foremost MDMA, alone and of itself, is capable of causing serious medical emergency and death. It is not required that an individual have obvious pre-existing cardiovascular pathology, nor that an individual take MDMA in a rave / dance environment. Second, that additional specific information on human decedents helps us to evaluate hypotheses related to factors, both exogenous and endogenous, which contribute to medical emergency or death in the Ecstasy consumer.