On MDMA-related deaths and fatalities in Australia, 2001-2005

Jul 23 2009 Published by under MDMA

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.

17 responses so far

  • Lee Nunn says:

    82 deaths in 4.5 years, 15 of which directly from the MDMA, and this worrying, come on do me a favour!? Theres no mention of how many MDMA doses were taken in that time so no ratio between doses taken and deaths. A similar study was done in New York state and although they had fewer fatalities, approx 50 if I recall correctly, they did estimated that 110 MILLION MDMA doses had been taken by New Yorkers in the same time period; 50 deaths from 110Million doses, come on that doesnt indicate MDMA to be a seriously dangerous compound now does it? Theres more deaths per year from peanut reactions than MDMA. Another US study concluded that Cheerleading was a more dangerous pastime than recreational MDMA use! And i havent even started on the " what about deaths from alcohol and nicotene " argument. MDMA like all compounds should be treated with respect and not abused. Most deaths are caused by adulterants mixed with MDMA like the nasty BZP and all the other nasty piprezines. And why are these nasty compounds found in XTC pills? Because MDMA is illegal and as soon as you prohibit something the criminal world gets involved and starts to cut corners and costs and flood the market with dangerous pills. Its a complete farce.

  • Mu says:

    Well, there were only 13 unintentional firearm related death in the US for children under the age of 4 in 2006, with an age group population of 20,000,000. With your logic, handing out guns in pre-school is save.
    Or maybe it's because we're getting good at preventing kids from handling guns.

  • DrugMonkey says:

    Most deaths are caused by adulterants mixed with MDMA like the nasty BZP and all the other nasty piprezines.
    The evidence does not support this claim so please let us know how you come to this conclusion. Did you even read this post?
    1) Just because other drugs are also on board does not mean they were the causal agent.
    2) The mode of death for mixed-drug fatalities that include MDMA are frequently highly similar to those that seem to only involve MDMA. Also quite similar to preclinical models where it is known that only MDMA is on board and highly dissimilar to the modes of death from the individual agents alone (esp, the opiates and alcohol and benzos). It quickly becomes a laughable stretch to maintain that MDMA is not a causal agent.
    3) If MDMA causes fatality by interaction with other extrinsic or intrinsic factors this does not magically refute the notion that MDMA is a causal agent.

  • Ramel says:

    Austrailin Gov stats on rates of drug use:
    Rates of ecstacy use here, starting page 22(dated 2004):
    Population of australia = 21,855,575 of which about 7% are between 20 and 24 years old(Austrailian bureau of Statistcs) of which the drug stats suggest 6.1% used ectasy in the month prior to data collection, so roughly 1.5 million in this age group with 90 thousand recent users, though I'm struggling to get a clear picture of how many these are regular users(this of course assumes that the goverment stats are even almost accurate, and I haven't made any ridiculous errors).
    As far as drugs go 82 deaths in 5 years doesn't seem that bad in this context, definatly not good, but compared to how many in this age group will have died from alcohol for example. Of course non of this takes into account other medical problems that may be caused be drug use, including long term brain damage and non-fatal emergencies. Probably not a good idea to take the drug, but probably not going to kill you. My position remains legalise it and let idiots use it at their risk.

  • Neel Bee says:

    They didn't seem to discuss isomers at all. As I recall, the l-MDMA is more toxic than the d-MDMA. It also has a more "physical" effect. I read that MDMA causes some permanent (?) damage to serotonin receptors, also isomer-dependent. I wonder why some people didn't try switching to N-methyl,2-methoxy, 4-5 methylenedioxy amphetamine (MDMA with an ortho-methoxy added) since the straight amino version MMDA-2 is about 3-4 x the potency of MDA or MMDA.

  • Elyse says:

    Well, there were only 13 unintentional firearm related death in the US for children under the age of 4 in 2006, with an age group population of 20,000,000. With your logic, handing out guns in pre-school is save.
    Or maybe it's because we're getting good at preventing kids from handling guns.

    Yes, that's it. America is winning the War on Drugs! Finally!
    This analogy is a total fail. Children's issues are not comparable to adult issues. Adults are allowed to carry firearms, and they should have that right. It's worse than ecstasy though, because you can turn a gun on another person. Ecstasy is relatively safe when compared to other recreational/everday activities whether it be rock climbing, driving, eating peanuts, using power tools, or taking OTC medications.
    I think that all the author of this blog has had to say on the subject of MDMA is "it may kill you." I'm pretty sure most everyone knows that, and I think it is arbitrary to single out MDMA use as idiotic and deadly. Many people derive much pleasure, enjoyment and sometimes meaning from MDMA experiences. They do it at their own risk, as adults do many things at their own risk, and that should be legal.
    I think by the logic of keeping substances like MDMA illegal, the government should continue to pass laws to control all other adult behavior with risk comparable to MDMA so that soon our lives will be reduced to the likes of pre-schoolers.

  • DrugMonkey says:

    I'm pretty sure most everyone knows that,
    I beg to differ. From comments such as the one posted first here, to interacting with students, to comments on almost every newspaper that covers an Ecstasy death to some opinion bits in a scientific journal or two...there is a distinct viewpoint that counters your belief. This viewpoint looks for any and every other contributing cause in an attempt to avoid recognizing that it is MDMA itself that is causing harm.

  • MadScientist says:

    Was any effort made to look into how the coroners' offices arrived at the dosages in blood? I'm always very dubious about other peoples' analysis; there's no telling what sort of monkey did the test. I can't even sit a small group of chemists at an Abbe refractometer and get them all to give me the correct reading and in the case of drug tests it is not at all unusual that the person doing the test is 100% clueless.

  • Catharine says:

    Are there any data that show older users have an increased risk of death? Is it significantly more dangerous to take when you are 40 rather than 20?

  • DrugMonkey says:

    Catharine, I would be very surprised if anyone had a good answer on that. The younger people really dominate the user population. Thus the fact that most deaths are youngsters has to be compared to an uncertain population in terms of stratifying use levels, chronicity, etc across age cohorts. My read is that we just don't have the data to answer your question. It is an interesting one

  • Jafafa Hots says:

    Never used the stuff, but as someone with PTSD, I am interested in studies of its use for this illness... I have heard that people have used it for this, but nothing really in the way of results.
    I doubt it could be any worse really than the crap that I was prescribed (and fortunately got off of)

  • Lab Lemming says:

    Don't have journal access, but I was wondering. Do they include traffic fatalities where the driver was toxed in the significant contributor category?
    It is also worth noting that in Australia, extreme summer temperatures and active lifestyles make hyperthermia a significant environmental risk to non-drug-users; it is a rare January where someone doesn't kill themselves by going for a lunchtime jog.

  • Mu says:

    @4, your own numbers say you have 90,000 users and 82 death over 5 years. That's 1/1000 will die directly of the drug in 5 years, that sounds significant to me.
    @6, my argument was purely for the uselessness of using a statistical argument to declare something "safe"; I personally think the war on drugs is a failure and should be rethought.

  • Ramel says:

    I point out 90,000 users in a single month in a narrow age group (20-24 years), the 82 deaths is for all age groups and gives a median age of 26, and if read my first comment I did not say that the death rate was insignificant, just that is not instant suicide to take the drug and people should be allowed to use it at their own risk. As well as noting several serious weaknesses with my information, this was only an example in anttempt to gain a little perspective for my self that I decided to share, I'm not trying to get it published in a journal.
    As a side note I picked the 20-24 age group for an example as the group with the highest percentage of users (6.1%), the fact that the median age is higher than this suggests that catherine's question is a good one and may well be worth further study. It is also possible that as younger people are more likely to start taking the drug that older users are more likely to be long term users, that could skew the results.

  • Ramel says:

    That second paragraph sould say "the fact that the median age of death is higher than this"

  • Winona says:

    Seeing as how the last post was made last year I do feel a bit hesitant and silly on even commenting. Unfortunately this is honestly the most informative site I have found in relation to my query.
    A little over a year ago a very close friend of mine lost her brother. He was 20 and he took ONE tablet of E, he had a seizure, and they couldn't bring him back. So a couple nights ago when I was thinking of the words I was going to use in my XTC critique for some users, I realized that I did not understand the science behind that one deadly pill. It had always seemed to me, that people around me were aware that one deadly pill could do that, just one. However, as I began my quest (and I must confess that my search engine skills are very poor, I often can't seem to find what I'm looking for) I cannot find one God damned website that has any stories or info on the tragic case in which a person takes ONE pill, not an overdose, just a bad pill. Furthermore I have discovered that there is tons of pages that all display MDMA/XTC as a drug with a rare case of overdose and death. NOTHING on how much is too much, NOTHING on the cause of why people take one and die, but all that and a bowl of cherries about how XTC precautions are merely a government conspiracy, an EXaggeration, a myth (much like pot). In fact people even question the rare deaths that do occur, implying that those deaths aren't even due to XTC nevermind MDMA. Their skepticisms convey their lack of experience with XTC death.
    Now there are two significantly disturbing things I am seeing. Firstly, is that the people on the defense of MDMA use commonly say that the numbers of death are small. This demonstrates to me that they clearly don't personally know anyone who died from usage nor do they empathize with the people who have had to lose. When you lose a loved one, do the statistics really matter? The number of Jeffery Dahmer victims is relatively small too! But I know the grievance those families have to go through makes it clear that small numbers do not make the cause of death negligent. The second thing that really grinds my gears is that people are debating with statistics and science experiments instead of their own stories. It's sensical in a way, if your loved one died from taking a small amount of XTC would you really wanna strain yourself to communicate online with people who only see the XTC death as a distant number, not a personal encounter?
    If anyone has any credible information as to why and how it is possible for a user to take only one and die please post the links. By the way, I am aware that the source of death could have been an agent and it is highly unlikely that this individual in particular developed a sudden allergic reaction to MDMA, and his medical records showed no conditions of heart or seizure problems prior to his consumption.

  • [...] You will recall, of course, that I have a great deal of blog interest in discussing MDMA-related fatalities. A Case Report that recently appeared in the Lancet helps us to connect up some dots. Sammler and [...]

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