Ecstasy (MDMA) toxicity

Background

MDMA
Ecstasy tablets containing MDMA
  • 3,4-methylenedioxymethamphetamine (MDMA)
  • Also known as: Ecstasy, X, Molly, Skittles, Smartees, Beans
  • Popular at "rave" parties and EDM festivals
  • Causes catecholamine release, serotonin release, and inhibits serotonin re-uptake
  • 1-2mg/kg effective dose; onset 30min-1 hour, peak 4 hours, lasts 8-24 hours
    • Typical tablets contain 50-100mg of MDMA

Clinical Features

  • Euphoria
  • Agitation
  • Tachycardia, palpitations, hypertension
System Minor or moderate overdose Severe overdose
Cardiovascular
Central nervous
system
  • Hyperreflexia
  • Agitation
  • Confusion
  • Paranoia
  • Stimulant psychosis
Musculoskeletal
Respiratory
Urinary
Other

Differential Diagnosis

Sympathomimetics

Drugs of abuse

Evaluation

Hallucination workup

  • Urine pregnancy
  • CBC, Metabolic panel, LFTs, coags, APAP level, ASA level
  • Total CK level
  • ECG
  • UA
  • Tox screen, blood alcohol
  • Serum osmoles, urine Na (if Hyponatremia present)
  • Head CT as indicated
  • LP to rule out Meningitis if infectious symptoms and based on history and physical
  • Urine tox fails to detect unless large doses
    • More usually positive test for amphetamines
    • Confirmation must use specialized lab tests (gas chromatography)

Management

  • Supportive care is mainstay of treatment
  • Benzodiazepines for agitation, severe hypertension
  • Hyperthermia may be severe and requires immediate treatment with active cooling measures
    • Morbidity/mortality is related to severity and length of hyperthermia

Disposition

  • Consider discharge if all symptoms resolve and no complications noted
  • Otherwise admit

References

  1. Aitchison KJ, Tsapakis EM, Huezo-Diaz P, Kerwin RW, Forsling ML, Wolff K. Ecstasy (MDMA)-induced hyponatraemia is associated with genetic variants in CYP2D6 and COMT. J Psychopharmacol. 2012;26(3):408-18

See Also