II. Pathophysiology
- Background
- Illicit Drug used at raves and clubs
- Street drug names include Lover's speed, molly, X, ecstacy
- Typically available in pill form (but may also be snorted, or drank as a liquid)
- MDMA is commonly mixed with other unlisted substances
- May contain Caffeine, Pseudoephedrine or Methamphetamine
- May contain Hallucinogens (e.g. LSD, MDA, MDEA, 2-CB)
- Variants: Mandy or Molly (crystalline powder form or MDMA)
- Promoted as "pure" MDMA (erroneously since powder form is more easily modified)
- Commonly adulterated (cut or replaced with cheaper, often more dangerous products)
- May contain Amphetamines or stimulants
- Contaminants include PMA ("chicken" or "death"), Methylone, bath salts
III. Mechanism
- Type of Amphetamine, with chemical structure similar to Serotonin
- Stimulant effects and Psychedelic effects
- Results in increased energy and pleasure (esp. with tactile stimulation)
- Stimulates Serotonin, Dopamine, and Norepinephrine release
- Serotonin release effects are 10 fold greater than with Methamphetamine
- Results in intense mood effects and negative withdrawal effects after brain Serotonin depletion
- Also stimulates release of Cortisol, Oxytocin, Antidiuretic Hormone
- Inhibits monoamine oxidase
- Limits breakdown of Neurotransmitters
IV. Pharmacokinetics
- Onset: 30-60 minutes after oral intake
- Duration: 3-8 hours
- Doses are often repeated to sustain effects
V. Symptoms
- Initial
- Agitated
- Time sense is altered
- Decreased hunger and thirst
- Later
- Euphoria
- Sense of intimacy with others
- Sense of well-being
VI. Adverse Effects
- See Sympathomimetic Toxicity
-
Trismus or Bruxism
- Users reduce this by sucking on Pacifier or lollipop
- Sympathetic overdrive
- Agitated or violent
- Tachycardia
- Mydriasis
- Diaphoresis (severe)
- Urinary Retention
- Hypertension
- Serotonin Syndrome
- Hepatotoxicity
- Hyperthermia
- Secondary to CNS Stimulation
-
Hyponatremia
- Secondary to SIADH (renal free water reabsorption) and increased fluid intake (Water Intoxication)
-
NMDA withdrawal related depression
- Associated with Serotonin depletion
- Longstanding effects
VII. Drug Interactions
-
Ritonavir (Norvir)
- Potentiates MDMA
- Cardiac Arrest and deaths have occurred
VIII. Labs
- Urine toxicology is unreliable
- Ingested MDMA may be too low dose to detect (despite causing significant toxicity)
- Contaminants are not typically detected such as cathinone (bath salts) or piperazines
IX. Precautions
- MDMA (Molly, Ecstasy) is unsafe at any dose (hyperthermia may occur at low dose)
- Associated with numerous deaths and ED visits since introduced in 2004
- Deaths have occurred regardless of MDMA form, whether "pure" or contaminated (e.g. bath salts)
X. Management: Toxicity
- See Sympathomimetic Toxicity
- Supportive Care
- Benzodiazepines for Agitation
- Treat hyperthermia aggressively
- Cooling and Benzodiazepines are typically used
- Rapid Sequence Induction and paralysis may be required
- Treat Severe Hypertension
- Benzodiazepines (first line management)
- See Hypertensive Emergency
- Other medications used in MDMA induced Severe Hypertension
XI. Management: Substance Abuse
- Cognitive Behavioral Therapy
- Recovery support group
- No specific management protocols or medications have been identified
XII. Complications: Class effect of stimulant Drugs of Abuse
XIII. References
- (2013) Presc Lett 20(12): 72
- Nordt and Swadron in Herbert (2014) EM:Rap 14(5): 9
- Tagliaferro (2023) Crit Dec Emerg Med 37(1): 21-9
- Gahlinger (2004) Am Fam Physician 69:2619-27 [PubMed]
- Klega (2018) Am Fam Physician 98(2): 85-92 [PubMed]