Death by ecstasy

Last week this column ended with a comment about the risk of death from ecstasy and that even though many people see the drug as benign, the reality is that it can cause death. The response to that piece has been quite amazing. I have had calls and emails from readers who simply don’t believe that ecstasy by itself can cause death, and that those fatalities that have occurred are solely due to impurities. So what’s the story?

A review article has just been released in this month’s edition of Psychopharmacology which gives an overview of ecstasy-related fatalities. It provides an extremely interesting insight into an area that has not been examined in any detail before.

Perhaps due to a number of reasons the rate of ecstasy-related deaths seems to have peaked in recent years. Estimates of the risk of using ecstasy vary considerably, from one death in 2000 first-time users to one death in 50,000. There were 72 ecstasy-related deaths in the UK in 2002, six times more than in 1996.

Even though death is not a likely outcome after taking the drug, ecstasy-related emergency department visits in the UK increased progressively and dramatically during the 1990s (often doubling from year to year) with visits tending to be for overdoses and unexpected reactions.

The metabolism of MDMA is regulated by levels of particular enzymes, and a small increase in dosage can lead to a significant rise in drug plasma concentration (or levels of the drug within the blood).

Due to their tolerance to MDMA’s psychoactive effects some individuals take greater amounts of the drug in an attempt to get the same effect they are used to. But increasing the number of pills you take dramatically increases the chance of something going wrong.

It has been estimated that the lethal dose of ecstasy could be between 20-30 tablets in a 70kg user, however deaths have occurred at doses far lower than that. There are many physical complications which have been reported associated with ecstasy use, all of which have been exacerbated by environmental conditions such as a hot, crowded nightclub or dance event.

Many reported deaths are found to be polydrug deaths, i.e. the user has taken more than one type of drug in one session. On other occasions, MDMA is the only drug found at post mortem and this occurs in up to 28% of all reported cases. What has led to many of these deaths continues to cause controversy: is it an individual’s innate vulnerability or is it some other unique characteristic of the drug that has not yet been identified?

The article suggests that we have to collect much more information on ecstasy deaths if we are ever going to answer this question. The authors suggest accessing the following: medical and psychiatric history of the victims; full history of drug use; quantity of drugs taken on the last occasion and the characteristics of the venue attended prior to death. Perhaps such information will assist us to understand these deaths a little better.