Tracking MDMA-related medical events in the aftermath of a rave event

Jun 16 2010 Published by under Drug Abuse Science, MDMA

The CDC has an interesting report out in their Morbidity and Mortality Weekly Report (MMWR).

Ecstasy Overdoses at a New Year's Eve Rave --- Los Angeles, California, 2010

This bit overviews a report from the Los Angeles County Department of Public Health which sought information on Emergency Department visits and other fatalities involving people who attended a New Year's event Dec 31, 2009-Jan 1, 2010. The investigation determined that

18 patients visited EDs in LAC for MDMA-related illness within 12 hours of the rave. All were aged 16--34 years, and nine were female. In addition to using MDMA, 10 of the 18 had used alcohol, and five had used other drugs. Three patients were admitted to the hospital, including one to intensive care. A tablet obtained from one of the patients contained MDMA and caffeine, without known toxic contaminants.


One of the rather unique and interesting features is that the report presents a timeline of when the rave attendees showed up in the local emergency departments.

CDCravereport.gif
FIGURE. Number, drug use, and arrival times of rave attendees transported to emergency departments (N = 30)* --- Los Angeles County, California, December 31, 2009--January 1, 2010 § Patient consumed additional ecstasy after the rave.[source]

Otherwise this is pretty run-of-the-mill stuff. Usually such emergency events are relatively rare but given there were an estimated 45,000 attendees at the event (an unknown number consuming Ecstasy of course), getting 30 cases sounds about right. And the clinical profile is familiar as well:

Clinical findings among the 18 patients with MDMA exposure were consistent with MDMA use (1,4), including agitation, hypertension, mydriasis, and tachycardia (Table). Fifteen of the patients were treated and released. Three were admitted. Two were treated for 2 and 4 days, respectively, and discharged in good condition. One patient was admitted to the ICU with seizure, rhabdomyolysis, renal failure requiring hemodialysis, and hepatic failure; he was discharged to home outpatient hemodialysis after a 28-day hospital stay.

Additional reading from me on MDMA:
Street Ecstasy content
MDMA-associated deaths and fatalities in Australia
It really was the MDMA that killed him
Translating doses between humans and the laboratory animal models
Parsing news reports on MDMA-related fatality

22 responses so far

  • Pascale says:

    I'm curious about the patient admitted to the ICU with rhabdomyolysis- was MDMA the only drug in that person?

  • vig says:

    You're conflating "MDMA" and "Ecstasy". Street Ecstasy is very rarely pure MDMA, and often has no MDMA at all in it. Check the DEA stats on that.

  • Craigenator says:

    @vig there is no conflation in this article. It doesn't mention "ecstasy" at all. It mentions MDMA. They determined which substances had been used by toxicology tests, not merely by self reporting of the patients. If you click the link at the top of the article it explains all of this.

  • DrugMonkey says:

    I'm curious about the patient admitted to the ICU with rhabdomyolysis- was MDMA the only drug in that person?
    I can't see where it specifies for this guy. This is so common in MDMA cases that it is one of the signature clinical symptoms if you ask me. Glad to have an expert around to explain things to me though. Would you point to other obvious causes? What should I be looking through case reports for?

  • JohnV says:

    Ok so I just looked up "rhabdomyolysis". Are people literally dancing (well "dancing") themselves to the point that their muscles break down and the debris causes kidney failure?

  • DrugMonkey says:

    to the point that their muscles break down and the debris causes kidney failure?
    No, I believe the thinking on this is that you get seizure (triggers for which my be hyperthermia, the hyponatremia or some other; perhaps in combination, perhaps with underlying constitutive sensitivities) which produces severe and sustained muscular contraction. I don't think dancing alone is enough to do it but I'd be open to correction from some exercise physiologist types.

  • JohnV says:

    Oh, that would make more sense. Not sure why I glossed over the seizure part in wikipedia. Anyhow good blog post, I've learned several things!

  • Epidemiologist says:

    I wrote the MMWR article. To answer the question above, the only drug taken by the ICU patient was MDMA, by self-report from the patient and confirmed by toxicology testing.
    As the report states, the tablet we obtained from the ICU patient was analyzed and we found only MDMA and caffeine in nearly equal proportions, along with a minor amount of N-methylphthalimide ( seizure --> muscle breakdown --> massive increase in CK --> renal failure.

  • PalMD says:

    It seems unlikely that dancing would lead to rhabdomyolysis without a preexisting inborn error of metabolism.
    When I have seen significant rhabdo associated with physical activity it has been severe stress, such as forced marches in high temperatures.

  • Isis the Exercise Physiologist says:

    Exercise-induced rhabdomyolysis is not uncommon although it is usually asymptomatic. See here.

  • ginger says:

    Hey, Epidemiologist, that is a beautiful example of outbreak investigation and reporting. I will probably use it as a teaching example at some point, that's how beautiful it is. Nice work! (I mean, bummer about the overdoses and all, but still.)

  • Epidemiologist says:

    Aww thanks ginger! It was a nice change of pace from our usual investigations of foodborne outbreaks and from the 'all H1N1, all the time' theme of the last year.

  • Klem says:

    @Epidemiologist, thanks for answering questions on this blog. How many people had a "serum toxicology test positive for MDMA" versus only a "urine toxicology test positive for amphetamine", which is "not specific for MDMA"? What were the other illicit drugs mentioned? What were the conditions at the event (water, temperature, ventilation)?
    As mentioned in the "Editorial Note", there were 2 deaths and 5 critical illnesses at a May 2010 SF rave, this SF event has been criticized as being very crowded, hot, and unventilated, with limited access to water. MDMA can be dangerous on its own, but these conditions seem to increase the risk.
    Gov. Arnold Schwarzenegger has ordered a review of event guidelines. I hope that CA will implement public-health regulations, like in the Netherlands, mandating access to water and adequate ventilation.
    For a through review of ecstasy-related deaths and ER visits (as well as neurocognitive testing in ecstasy users), see this free article (cited by the CDC) by an independent meta-analysis team:
    Rogers G, et al. The harmful health effects of recreational ecstasy: a systematic review of observational evidence. Health Technol Assess. 2009 Jan;13(6).
    The Rogers et al. review was commissioned by the UK state-sponsored ACMD, which recommended in 2009 that MDMA be downgraded to a class B drug. The ACMD report contains a summary of MDMA risks:
    A review of MDMA ('ecstasy'), its harms and classification under the Misuse of Drugs Act 1971. Advisory Council on the Misuse of Drugs (ACMD). 2009.

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  • Simon says:

    From the article...
    "urine toxicology testing for amphetamines is not specific for MDMA"
    So given this, a number of them could have taken some other amphetamine(s) as well as pills, or only amphetamines.
    Epidemiologist, if you're still around - any idea of the blood/urine levels of amphetamine/MDMA in any patients? And is there a reliable means of working out the volume of MDMA ingested from these figures? (I note the self-reported range in the article as 1-6 pills)

  • Epidemiologist says:

    Simon, I don't quite understand your comment:
    "So given this, a number of them could have taken some other amphetamine(s) as well as pills, or only amphetamines."
    Yes, they could have taken other amphetamines. I'm not sure what you mean by 'as well as pills'. To clarify, MDMA is an amphetamine. Most amphetamines, including MDMA, taken by rave attendees are ingested in the form of pills/tablets or capsules. Although some people do inject crystal meth, surveys suggest that injecting drug use is uncommon at raves. So the patients could have taken only MDMA, MDEA, MDA, PMA, methamphetamine, Adderall or other ADD drugs, or only some other amphetamine, or any combination of these, and all would be reported as a positive urine test for amphetamines in general on the tox screen. That is why we made the statement about the lack of specifity of urine toxicology screening for MDMA. However, I can say that all the patients were seeking to take "Ecstasy" and not other amphetamines. On the other hand, it is relatively common for purported "Ecstasy" tablets to contain other amphetamines or other drugs instead.
    Urine tox screens are reported only as positive or negative. Levels are not reported. Thus we had to rely on self-report for amounts ingested; however, since MDMA illicit tablets are not as uniform in composition as legitimate pharmaceuticals, individual tablet weights as well as the actual composition are not uniform and thus it is difficult to conclude much about the dose ingested from the reported tablet number. Average street 'Ecstasy' tablets that contain MDMA generally contain between 50-150 mg of MDMA, but it is hard to conclude much about the individual patient tablets. For the one tablet we analyzed, we could not formally report the mg of MDMA since the DEA lab will only do this when 10 or more tablets are available for testing (for reason above about non-uniform composition), however if reported it would have fallen in the normal range.
    Serum MDMA levels would be much more informative but few ED physicians order these because they are generally 'send out' tests that will take a week or more to come back and not help in the clinical management of patients in the emergency setting. That being said, there was one patient included among the 18 cases with a serum MDMA level of 310 ng/mL (reporting limit 50 ng/mL). No MDA or MDEA were detected.

  • DrugMonkey says:

    Simon,
    There is another point that is touched on in the Editorial Notes and is something that I hammer away at on occasion on the blog.
    MDMA fans wish to explain each and every case of Ecstasy-associated medical emergency and/or death as everything under the sun other than MDMA itself. And yet, take a look at the consistent clinical picture across many individuals who may or may not be positive for meth, PMA, co-ingestion of alcohol, cannabis or nicotine. Consistent across settings (rave or at home).
    Where MDMA is the unifying factor.
    Check how consistent the clinical profile is with animal research in which the drug identity is known. Then compare that against modes of emergency or death for alcohol or nicotine or even methamphetamine.
    It is the *MDMA*.

  • DrugMonkey says:

    MDMA fans wish to explain each and every case of Ecstasy-associated medical emergency and/or death as everything under the sun other than MDMA itself.
    Oh look, there was one stuck in the filter.
    but these conditions seem to increase the risk.
    Do tell. The rodent data perhaps support the notion that high ambient temperature is a problem but the human and nonhuman primate laboratory data do not. Quite the contrary. And we all know how people of your ilk feel about the doses used in the rodent studies...
    Case reports from the quiet home setting are easy enough to find and they do not present a substantially different picture from the ones where the person was in a rave. So you probably need good estimates of rate in each setting to make headway on this claim. Do you have such estimates? Epidemiologist's report is the first I've seen to track a single event in this way so I really, really doubt you have the necessary evidence. I doubt it exists, in fact.
    Lack of water- again minimal evidence that this contributes to MDMA-associated hyperthermia and in fact the Freedman 2005 human lab study gives a clue- people stop sweating on MDMA. Or at least the threshold is higher. So if evaporative cooling is impaired, it is unlikely to be related to availability of drinking water. And remember, MDMA releases vasopressin, causing fluid to be retained.
    Ventilation- Uncertain what you are claiming here. Not temp, obviously, since you listed that as a separate risk category. Oxygen? Humidity? I don't think O2 levels have been experimentally tested but I seem to have a vague recollection of a humidity investigation. Probably in rodents though. Perhaps you have a better recollection than I for such a paper?

  • Epidemiologist says:

    Klem,
    To answer your questions, as I explained in a previous comment 1 person had a serum toxicology test positive for MDMA; the rest were urine tox positive. It is rare to find a chart containing a serum MDMA level on an ED patient since they are not useful for immediate clinical management and take a long time to come back, at least a week. That is why most of the time we only have serum MDMA levels on patients who die, since levels will get checked by the coroner/medical examiner to help establish cause of death.
    The other drugs included both illicit and prescription pharmaceuticals: LSD, marijuana, benzodiazepines.
    In terms of conditions at the event, we became aware of this event 4 days after it happened so were not on-site, and ambient temperature in the venue is not routinely recorded by facility management. There were no particular participant complaints about ventilation problems or temperature that I am aware of. The price for bottled water at this venue is $5/bottle (seems outrageous to me, but this is the same price as for sporting events and all other events held at the venue), but there is also free water at water fountains located outside every bathroom in the facility.
    The San Francisco rave was tragic and in addition to the two deaths, there are still two people in intensive care.
    I am glad to see that you agree that "MDMA can be dangerous on its own." I think there is a lot of denial in the community of MDMA users about this.

  • Epidemiologist says:

    Also wanted to mention, the "Editorial Note" in an MMWR article is actually written by the author and not, as most people assume, the MMWR editor. It essentially serves as the discussion section of the paper.
    And I agree with DrugMonkey's comments above about the heat/ventilation/water issues. I also have some concerns about recommending that MDMA users drink water, because once people have become dehydrated, ingesting free water can exacerbate hyponatremia, and hyponatremia-related cerebral edema can cause death. It would probably be better to drink sports drinks, soda, or juice instead of water.

  • DrugMonkey says:

    I think there is a lot of denial in the community of MDMA users about this
    Yeah, you could say that. Very much active denial. They are relatively informed on the science compared to the cannabis fans. Still. The way they cherry pick papers is a sight to see...

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