Chapter 24-16: MDMA (Ecstasy or Molly) Intoxication

TEXTBOOK PRESENTATION

Patients are typically college students, attending clubs (raves), who often present on the weekend with anxiety, restlessness, delirium, or seizures.

DISEASE HIGHLIGHTS

1. MDMA is a synthetic illicit sympathomimetic amphetamine that stimulates the release of norepinephrine, dopamine, and serotonin, and blocks their reuptake.

2. Causes increased alertness, euphoria, sexual arousal, and disinhibition

3. Frequent drug of abuse (up to 4.4–10% of high school seniors and 39% of US college students have reported use). Its use has been reported in 60–76% of rave participants. Accounted for 44% of patients requiring medical support at an electronic dance festival.

4. Symptoms and signs among emergency department visits for MDMA use include agitation (38%), anxiety (29%), disorientation (25%), shaking (23%), hypertension (21%), headache (19%), mood changes (19%), psychotic disturbances (17%), loss of consciousness (13%), tachycardia (10%), dilated pupils (10%), hyperthermia (6%).

5. Serious complications have included hypoglycemia, hyponatremia, hyperthermia, malignant hypertension, stroke, CNS hemorrhage, coma, seizures, myocardial infarction, arrhythmias, aortic dissection, nontraumatic rhabdomyolysis, acute kidney injury, hepatitis, liver failure, disseminated intravascular coagulation, and death (even in first time users).

6. Commonly ingested with other drugs

7. Hyponatremia

   1. Discovered in 6% of MDMA-related emergency department visits.

   2. Hyponatremia may be severe and cause cerebral edema, seizures, coma, and death. The mortality in patients with MDMA-induced hyponatremia is 50%.

   3. Secondary to ADH secretion (SIADH) and water intoxication. The water intoxication is prompted by hyperthermia, diaphoresis, and increased thirst. It is further aggravated by “recommendations” to drink large amounts of water.

   4. Unlike other MDMA complications, women are more susceptible to MDMA-induced hyponatremia than men. (85% of the case reports of MDMA-induced hyponatremia have been in women.)

   5. Hyponatremia can occur after just a single dose.

EVIDENCE-BASED DIAGNOSIS

1. MDMA is excreted in the urine and can be detected by specific tests.

2. Numerous congeners of MDMA exist.

3. Urine studies may not detect various congeners and the diagnosis is often made clinically.

TREATMENT

1. The treatment of MDMA intoxication is beyond the scope of this text. Treatment will focus on the hyponatremia.

2. ICU monitoring is usually required.

3. For asymptomatic patients with mild hyponatremia, fluid restriction is usually adequate.

4. For marked symptoms (coma, seizures) hypertonic saline should be used (see Table 24-2). The risk of ODS is minimal in patients with MDMA-induced hyponatremia because the hyponatremia is acute.