Methylenedioxymethamphetamine, Ecstasy, MDMA

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