Here we go again. Ecstasy, death...unsubstantiated claims.

Nov 21 2009 Published by under MDMA

Canada. Again. This time in Whistler:

A 20-year-old male had been found unconscious by friends. When police arrived, Whistler Fire Rescue Service and Emergency Health Services personnel were performing CPR, but failed to revive the victim, who was pronounced dead a short time later at the Whistler Health Care Centre, Wright said.
A second male who was at the same home was hospitalized after he, too, suffered an apparent overdose of MDMA (methylenedioxymethamphetamine). He is expected to make a full recovery, Wright said.
Both men had ingested the drug in powdered form.

aaaand...

Earlier last week, a 17-year-old Fernie male who had also ingested MDMA in powered form almost died, Wright said, emphasizing that there was no connection between the two incidents.

Three overdoses requiring medical intervention, one death.


As always, it is very frustrating to see these news reports in advance of the tox screen data. Most usually the news media pick up the overdose / death story and run with it for a couple of days and then mysteriously fail to return to the story and publish the Medical Examiner's report on what drug and drug levels were found in the body. Some of this may have to do with privacy, I don't know although it seems silly that you can have all the situational reporting and yet the tox data are off limits doesn't it? I think this does a very specific disservice to public health. How so?
The problem raises its head in article:

Youth Outreach workers Davin Moore and Tara Souch .. are working with peer educators to get the message out that a tainted drug may be in circulation, as well as the general risk of taking drugs like ecstasy.
So far there has been no request for their services, but Moore and Souch are doing an investigation of their own.
"We actually had someone in our peer educator group that was close to the situation and they've been sharing information with us," said Moore. "It's good to get the information out to young adults that there could be a bad batch out there that is putting people in the hospital.
"From what I understand it wasn't a matter of taking too much, it was a single dose and the nurses believe it was probably a bad batch. It's definitely scary stuff, and the scariest thing is that it's unknown and anything could be in there... there's a stat going around that sometimes ecstasy in this province is half (crystal) meth."

And where is that stat coming from? Because most of the time this is just made up BS and has nothing to do with any specific, local and time-related information on drug content. Whatsoever. What is more likely is the general knowledge based on ecstasydata.org and the published literature on seized (and other) samples is being passed around.
"Could be a bad batch". Sure. It could be some non-MDMA drug which is leading to fatality. Or it might not. MDMA in and of itself is capable of causing these situations of medical emergency and death. It happens in animal models in which the drug and dose is known absolutely and environmental and situational conditions are held constant. The trouble, of course, is that in the human use condition these situational variables are not even remotely held constant. It should be obvious from the rather low rate of MDMA-related complications and deaths against the user base each and every weekend around the world that simple conclusions about the rave environment, dancing, non-MDMA pill content and even whopping dose levels are not the answer.
Nevertheless if we gate on the deaths and medical emergencies some consistencies do emerge. The clinical picture. A picture that begins with "found collapsed / unresponsive". Occasionally "abnormal movements / seizure". That continues, once medical services are involved, with a consistent picture of elevated body temperature, heart rate, blood pressure and sometimes continued seizure activity. Cardiac arrest. Hyponatremia (overly dilute blood) and kidney failure. Postmortem evaluation confirming a couple of additional features including intravascular coagulation and rhabdomyolysis.
My continued position is that if you consider the host of alleged non-MDMA reasons for these people to have gotten into trouble, not all of them would be predicted to lead to the same resulting clinical picture. Some of them, sure. But not all. To my read, which I will admit is very far from a casual one, there are some remarkable consistencies in the clinical picture including the verified presence of 3,4-Methylenedioxymethamphetamine in the body.
Where is this nurse belief in the "bad batch" coming from? I doubt very much that anyone has analyzed the content of drug that has been passing around Whistler lately. If they had specific knowledge about content, they would say so. What they mean, of course, is that people have been showing up with medical emergencies. And since they believe this to be unusual for genuine MDMA, they conclude something other than MDMA is the cause here.
They. Do. Not. Know. This.
And here is where the whole harm reduction and peer-counselor thing earns a big ol' FAIL. These people quoted seem to be out trying to reinforce the existing user beliefs that there cannot possibly be anything unsafe about MDMA, particularly taken in what are understood to be usual doses. Just read the comments, if permitted, for any news article on Ecstasy overdose and you will see what I mean. The attitude pops up on comments to my observations as well. This works against harm reduction.
The point being that IF (and I can always be wrong in my analysis, you know) MDMA is the problem, telling people that it is only the presence of, e.g., methamphetamine or PMA, or the "dehydration" (which is a red herring, btw) or the dancing or whatever points them in the wrong direction. It fails to point to the appropriate mechanism for reducing harm. Furthermore, all the proposed pie in the sky legalize-eet solutions having to do with providing people with known-content and known-dose Ecstasy won't do a damn thing* to reduce harm either.
__
*ok, ok, having known dose might help slightly. But only slightly. So long as people think there is a huge safety window for heroic doses (because, you know, it isn't the MDMA at fault) they are going to push it..

17 responses so far

  • lost academic says:

    This has the feel of the consistent media attention, typically proved to be falsified or nonexistent, on poisoned or drug-laced Halloween candy. (http://www.snopes.com/horrors/poison/halloween.asp) There are enough real problems without this nonsense.

  • DrugMonkey says:

    Well it may have that "feel" to you but if you bother to follow up with the links provided and, oh I dunno, actually read what I wrote you'll see that it is different. You know, case report in the literature, epidemiological study, police action and medical examiner toxicology report different.
    This is a very real problem for friends and families of those who die. Problem for those who render themselves (again, peer reviewed literature, here) stupid or anxious or depressed or otherwise screwed up via drug use. A real problem for those who become dependent.

  • ebohlman says:

    I think another factor here is people's failure to appreciate the "clumpiness" of random phenomena. If, say, MDMA intoxication alone has a small but non-trivial fatality rate, then MDMA fatalities are going to appear to come in "clusters" and people are going to think "something has changed" when in reality the distribution is exactly what you'd expect from a simple Poisson process.

  • DuWayne says:

    And here is where the whole harm reduction and peer-counselor thing earns a big ol' FAIL. These people quoted seem to be out trying to reinforce the existing user beliefs that there cannot possibly be anything unsafe about MDMA, particularly taken in what are understood to be usual doses. Just read the comments, if permitted, for any news article on Ecstasy overdose and you will see what I mean. The attitude pops up on comments to my observations as well. This works against harm reduction.
    Now what the fuck exactly, does this have to do with a fucking harm reduction/legalization fail? Good fucking grief DM, the point of harm reduction isn't to make ALL the harm magically fucking vanish. It is to reduce the harm. Legalization makes it easy to reduce harm.
    As someone who supports harm reduction and a harm reduction approach to drug use, I make it good and clear when I am talking to people about MDMA, that the evidence points to MDMA being potentially fatal. Not mixed MDMA, not dehydration, not anything but the MDMA. I also have to admit to them that such deaths are rare and often times we know very little about what actually happened.
    Here though, we have a huge clue. It was powder. The likely implication being that they one, weren't likely measuring their doses very precisely and two, they were putting it up their ignorant damned noses - either of which could, alone, speak to the problem. Without a tox screen, we are really unable to tell, but given the fact that it was powder, I have my serious doubts that we can chalk this up to normal dose, normal ingestion of MDMA causing the ODs. Snorting that shit is a hell of a lot different than fucking popping a pill.
    But then, you want to slam the shit out of the harm reduction approach to drug use and substance abuse/addiction treatment, based on fucking bullshit. Give me a break - I like you and often agree with you, but that was fucking bullshit and I suspect that you have some inkling that it was. I should at least hope you do.
    Considering that a harm reduction approach seems to be rather more effective at reducing the harm than most other forms of addiction treatment, you are making a rather baldfaced fucking claim here. And considering that you are basically calling those of us who support and approach drug use and substance abuse from a harm reduction standpoint denialists, you may want to take a look at my writing on the topic, as well as the writings of Dr. Andrew Tartarsky, Edward Khantzian, MD, and as much as I dislike her, Dr. Pat Denning. Denning and Tartarsky, in particular, are two of the pioneers of the harm reduction approach and while Denning tends to shy into what I consider the stupid from a theraputic standpoint, none of these folks are science denialists in the least. Even Dr. Stanton Peele, another one who tends to annoy me a bit for various reasons, is not a denialist either.
    You really need to either shut the fuck up about harm reduction and the views of harm reductionists, or you need to find out exactly what the fuck you are talking about first. Because your commentary on harm reductionists and those who come from that stance in supporting legalization is absolutely fucking clueless.

  • From what I have heard from people who did X back in the 80s when pure MDMA was easily available, the typical route of administration was dissolving powder in orange juice and drinking it.

  • DuWayne says:

    CPP -
    Sure, that might be what they were doing with it, but given the penchant a lot of kids these days have for sticking so many different drugs up their noses I sincerely doubt it.

  • Klem says:

    The Canadian police (RCMP) have been warning about fake or tainted ecstasy for years.
    Most recently, Montreal Gazette (Nov 17, 2009):
    "The Health Canada study, conducted in cooperation with the Sûreté du Québec and other Quebec police forces and released yesterday, analyzed 365 tablets seized across the province between June 2007 and July 2008. It showed that... only 23 per cent of drugs sold as ecstasy (MDMA) really were ecstasy."
    And from 2005: Most ecstasy spiked with meth, RCMP find
    Methamphetamine overdose is similar to MDMA or other stimulants - increased temperature, heart rate, blood pressure, etc.

  • Simon says:

    Is it mandatory to swear a lot in these comments? 😉

  • DrugMonkey says:

    no it is not mandatory to swear. most do not.
    Duwayne, I *do* know about harm reduction efforts and I was quite obviously talking about these specific ones and their apparent (from the press report) following of the usual "oh it can't possibly be the MDMA" nonsense. Which, as you know I talk about quite a bit.
    Your brand of harm reduction sounds just fine to me. So get off your high horse already. My point is that if so called harm reduction people's idea of harm reduction is to tell people to watch out for the "bad" Ecstasy while overtly or covertly supporting the notion that these folks couldn't possibly have gotten into trouble because of MDMA, this ain't reduction. Or if they insist it was only wackaloon doses when the eventual tox supports something else entirely, ie. pretty normal doses (as it frequently does in the case reports) this ain't harm reduction.

  • Dunc says:

    Furthermore, all the proposed pie in the sky legalize-eet solutions having to do with providing people with known-content and known-dose Ecstasy won't do a damn thing* to reduce harm either.

    Well, other than nix the "non-MDMA" and "wackaloon doses" ad-hoc hypotheses people use to convince themselves that MDMA is perfectly safe whenever they hear this sort of story, and which you are specifically objecting to here.

  • wright says:

    Mr Bond, are you done with all your SPAM?. Look, there is a nice place in MD where you can try all your therapeutic skills for failing hearts and communication failure.
    John Wright

  • DrugMonkey says:

    Nice link Klem, I notice data, woot.

    Of the 137 tablets tested at Health Canada labs so far in 2005, 125 contained MDMA, or ecstasy. Of those 125, 95 contained meth. The median amount of meth in the tablets was eight milligrams, with 16 mg the high and four mg the low...As Rintoul pointed out, the typical dose of amphetamine given to pilots in the U.S. Air Force to keep them awake on long missions is about 10 mg.

    so a 10 fold difference between this meth dose and the consensus median MDMA dose. For reference, in the human lab studies of C. Hart they use 10, 20 and 40 mg of meth pretty routinely. including in comparison with MDMA at 100 mg oral.
    I'll have to poke around a bit more but I don't think we have support for this kind of 10-fold differential in the medical emergency parameters you mention. Certainly not in animal studies. here the go-to might be the work of Clemens, McGregor and colleagues where meth and MDMA are about equipotent in elevating rat body temp. The 2004 paper from that group looking at *interaction* of co-administered MDMA/Meth doesn't support that as a risk factor either. Although I'd be very interested in a better look at some drug combinations, myself. Not much study on this yet.
    finally we get to the note, which is not uncommon and I've cited a paper looking at this via focus group before, about users explicitly seeking "speedy" Ecstasy. Opens another bunch of scientific issues, see above, and also predictive ones. If you have populations that are going to mix Ecstasy and meth/d-amp in the wonderful legalizeet future you envision, you need to incorporate this into your risk evaluation. You know, instead of pretending legalization is going to magically make everything better...

  • DrugMonkey says:

    Dunc, you read the footnote, right?
    I tend to agree with you that on this, just seems like a lot of potential tragedy to finally punch through the message, doesn't it?
    Still, comprehensive tox on the medical emergencies (incl the ones that don't lead to death) would be *very* helpful for you all risk comparison folks, don't you think?
    I am not familiar with any effort to collect such data and it is a shame. This is where I would criticize the reflexively anti-drug public policy side for intentionally (so I would suspect) letting the message rest where it is- this imprecise sensationalist news reporting of the deaths. As always, that is my scientist bent. I think more info is better. But of course, I don't do work trying to understand how to change the behavior and attitudes of broad swaths of the public so my view on that is uninformed.

  • DrugMonkey says:

    Klem, one more observation on your link. It had one of those nonspecific allegations that in context tried to imply something which turned out to be untrue. It referred to the case of one Mercedes-Rae Clarke as follows.

    A 13-year-old girl died in September when she took what she and friends believed was ecstasy they bought from a street dealer in Victoria...Richard Stanwick, chief medical health officer for Vancouver Island, said an amphetamine overdose was suspected in Mercedes-Rae Clarke's death.

    I found a followup that said this:

    Sherry [MRC's mother] says the coroner’s office told her a few weeks later that the drug was pure ecstasy—not laced with crystal meth, as rumour had it. Sherry also wants the world to know: “Ecstasy is seen as the fun drug, the one to take to a party and have a good time with, not nearly as bad as crystal meth. But ecstasy can kill, too.”

    I wonder how many people become aware of the tox report after the sensationalist initial newscoverage of Ecstasy-related deaths? I certainly find it hard to Google out tox followup and the initial barrage of "it can't be MDMA" comments on the papers in question (and good ol bluelight) seem to dry up for those situations where the tox does come out...

  • Meat Robot says:

    Thanks for putting the focus back on Ecstasy itself as the likely cause of sudden death. I work on the clinical front line, and my population includes a very high burden of substance abuse and dependence, including crystal meth among homeless street youth and ecstasy, to a much lesser extent, but more prevalent in middle to upper class white youth.
    This type of information definitely helps me convey a clear message about harms. I've sometimes been seduced by the "tainted pill" hypothesis and sent along bad info, so thanks for setting the record straight.

  • DrugMonkey says:

    To be clear Meat Robot, I do not disagree that non-MDMA drugs found in purported Ecstasy can be dangerous. PMA has been a biggie, if perhaps temporally and geographically limited. By no means would I let methamphetamine completely off the hook and I doubt we have very good info about interactive effects. Still, there are some very strong similarities across many cases of medical emergency that do look very much as though MDMA is the causal agent even in those mixed-drug situations. Similarities that are consistent with the cases in which MDMA is the only apparent causal agent...as overviewed here.

  • DuWayne says:

    Sorry I took so long to respond DM, things are rather hectic at the moment.
    The problem is that you didn't just leave it at a criticism of the people in question - though even that may have been misplaced. You also slam the notion that legalization won't reduce harm, or will only slightly reduce harm.
    Let me address the peer counselor/outreach workers issue first. Peer counseling isn't perfect. By definition, it consists of people who are not professionals trying to disseminate sometimes complicated and nuanced information to their peers. This is further complicated by that information sharing being a two way street - an important aspect of peer counseling and to some extent harm reduction in general, is to listen to what substance users and abusers have to say about the drugs that are currently available in a given area.
    This is not always accurate, but short of managing to get samples of every single drug going around and getting them analyzed, it's the best we can manage. For the most part, this just consists of learning about drugs that are making people sick, or that are particularly strong (thus carrying an elevated risk of OD) and often drugs that are, or may be cut with something else.
    If you look at the statement you quoted, they do not ignore the dangers inherent to the drugs themselves. They aren't claiming anything like the idea that pure MDMA is somehow safe. All that they are saying is that they have been told by youth who have either used from this batch or who have friends who have, that there is meth in this batch. There are certainly a lot of variables that can affect the veracity of that statement, but they are working with what they have. And there is a very good reason that they will report this sort of information.
    There are a lot of people out there who have some experience with MDMA. They "know" how they will react to it and "know" how much they can take. The idea is to make sure that these kind of folks are aware that there may be another variable that they can't account for based on previous experience. That doesn't preclude trying to make these same people aware that their previous experience doesn't mean that the very same drug won't hurt them or kill them in the future. It just provides them with something that those kids are more likely to listen to and be concerned about. Because those kids who have all that experience are likely to be less concerned about the drug itself, the more experience they have with it not causing notable harm.
    As for the legalization argument - you pretty well hammered at that, without it being mentioned in the articles and without really addressing the what harm reduction advocates actually say about it. I really don't have time now to go into detailed explanations of the reasons harm reduction advocates support legalization, but I will list them and respond to specific arguments.
    First, it is not all about the addicts and users. Harm reduction is looking at this from an overall public health standpoint. The illicit drug trade is the single largest supporting element of organized crime in the U.S. today. Legalization would take a lot of the wind out of organized crime, because it would decimate the profit margins. Lumped into this is the immense amounts of money that we are throwing away to enforcement and incarceration, as well as the tax revenue lost. Money that could be used for better things.
    Second, having standardized and regulated doses, labeled ingredients and pharmaceutical standards of production is going to make a significant difference in the safety of the drugs themselves. That is not to say that it will make use safe and very few advocates of harm reduction would even imply it would. But when we are talking about people who are going to use, it would be preferable to have them know what they are actually getting and it would make it much easier to explain the actual risks involved with use.
    Third, it would make it easier to convince people who need help, to get help. And it would reduce the ethical concerns of therapists who recognize that even if abstinence is the goal, it may not happen immediately and that it is important to make sure that the client knows that successful therapy does not mean they can't touch that drug ever again - that today is the first day of sobriety and anything less is failure. That is something that drives a lot of people out of therapy. It also allows the therapist to recognize that the goal may not be abstinence at this point, that the goal is to help the client become a functional addict. While that may not be ideal, it is often the actual result and when the goal is to reduce harm, functional addiction may be a reasonable alternative to the non-functional status quo.
    And finally, it is very likely that legalization would be an important first step in changing our social addiction paradigm. A lot of what is wrong with our addiction paradigm is rooted in moral judgments that would tell us that the addict is just weak, lazy and prone to bad decisions. It makes it much easier to moralize it, when we can add criminal to that list.
    This is by no means comprehensive, either in my discussion of peer counseling or potential benefits for legalization. These are merely what I see as the most important. And I will not be getting off my high horse as it were, when I am not seeing any sort of distinction made between what you say you were actually criticizing and the vast majority of what harm reductionism actually speaks to. While the language of the article implies a bias, keep in mind that the youth outreach people didn't write the damned article and it may well be the writers own bias. Kind of like the sort of journalism that scientists rightfully get rather irritable about on a regular basis, when it comes to science reporting...

Leave a Reply