eMedicine Specialties > Emergency Medicine > Toxicology

Toxicity, MDMA: Follow-up

Author: In-Hei Hahn, MD, FACEP, Attending Physician, Department of Emergency Medicine, St Lukes-Roosevelt Hospital Center; Assistant Clinical Professor, Department of Medicine, University Hospital of Columbia, University College of Physicians and Surgeons.
Coauthor(s): David Yew, MD, Assistant Clinical Professor, Department of Surgery, University of Hawaii; Medical Director and Flight Physician, AirMed Hawaii/AirMed International
Contributor Information and Disclosures

Updated: Jan 26, 2009

Follow-up

Further Inpatient Care

  • Admission to an intensive care unit may be needed if evidence suggests presence of significant hyperthermia, altered mental status, seizures, severe hyponatremia, respiratory depression, or acute renal failure secondary to rhabdomyolysis.

Further Outpatient Care

  • Refer the patient for drug abuse counseling and treatment.

Transfer

  • Patients may require transfer to a psychiatric facility for evaluation and treatment if they exhibit dangerous behavior or psychosis refractory to general supportive measures and are stable without hemodynamic instability and with no evidence of cardiac, cerebral, renal, hepatic, or pulmonary complications.

Complications

  • Hyperthermia and the risk of serotonin syndrome can result in increased mortality with complications of DIC, rhabdomyolysis, and acute renal failure. Institute general cooling measures and treat rhabdomyolysis with generous intravenous hydration and alkalinization of the urine.
  • Monitor hyponatremia as a result of SIADH and excessive water intake for resultant cerebral edema and seizures. In severe cases, administration of 3% saline and furosemide may be indicated to correct the hyponatremia but at a rate no greater than 0.5-1 mEq/L/h.
  • As with any amphetamine, the risk of stroke, cardiac arrhythmia, and heart failure always is possible. The risk is especially high in patients with congenital abnormalities (eg, arteriovenous malformations, cardiomyopathy) or underlying heart and pulmonary disease.
  • Although the causal relationship between MDMA and liver toxicity has not been shown definitively, case reports document hepatotoxicity resulting in self-limited hepatitis and fulminant liver failure following MDMA use.
  • Always keep in mind the possibility of other drug ingestions. MDMA users often co-ingest other drugs, and ecstasy tablets can be combined with other drugs. Heroin, ketamine, cocaine, alcohol, and marijuana have been implicated, and the patient may present with a mixed toxidromic clinical picture.

Patient Education

  • Patient education is essential in communicating the short- and long-term risks of MDMA use. MDMA long has been perceived as a "safe" drug with few adverse effects and a long duration of action. However, tolerance develops quickly, and, with increasing doses, patients place themselves further at risk for complications of sympathetic hyperactivity leading to possible cardiac arrhythmias, hyperthermia, and hemodynamic instability. Patients must be informed of long-term psychiatric implications associated with regular use. Depression, anxiety, paranoia, and insomnia have been reported to last for years after cessation of MDMA use. In addition, studies have demonstrated impairment in concentration and memory associated with MDMA use.
  • For excellent patient education resources, visit eMedicine's Substance Abuse Center, Poisoning - First Aid and Emergency Center, and Mental Health and Behavior Center. Also, see eMedicine's patient education articles Club Drugs, Drug Dependence & Abuse, Substance Abuse, Poisoning, and Activated Charcoal.

Miscellaneous

Medicolegal Pitfalls

  • The pure ecstasy user is a rare entity. The overwhelming majority of persons who take ecstasy also use other drugs. In addition, ecstasy tablets may be mixed or cut with other substances. Always keep in mind the possibility of co-ingestion with opiates, ketamine, GHB, cocaine, alcohol, marijuana, and other drugs.
  • Hypoglycemia is always a possibility in patients presenting with neuropsychiatric symptoms. A rapid bedside glucose determination always is indicated; if needed, administer thiamine and glucose.
  • Failure to monitor core temperature and provide sedation, cooling measures, and adequate intravenous hydration is a potential pitfall. Monitor for rhabdomyolysis and treat it with alkalinization of the urine.
  • Failure to recognize hyponatremia as a severe complication of MDMA use is a potential pitfall. Numerous reports have demonstrated significant morbidity and mortality associated with hyponatremia-induced cerebral edema and seizures.
  • A negative urine toxicology screen does not exclude the possibility of MDMA abuse. Toxicology screens usually fail to detect MDMA unless large amounts are ingested.
  • Failure to recognize and evaluate other causes of delirium such as infection and trauma as well as failing to recognize secondary complications such as ischemia or infarction of organs, rhabdomyolysis, and NS sepsis.

Special Concerns

  • Beware of specific drug interactions that are potentially life threatening.
    • Patients with HIV who are taking protease inhibitors and ingest MDMA have had near-fatal reactions secondary to alterations in the cytochrome P-450 systems, resulting in an inability to metabolize MDMA.
    • Patients taking monoamine oxidase inhibitors (MAOIs) have had near-fatal outcomes when ingesting MDMA. Sympathomimetic-MAOI interactions can cause excessive serotonin and norepinephrine release, resulting in hypertensive crises, intracranial hemorrhage, and severe hyperthermia.
  • Pregnancy presents special concerns.
    • MDMA, like other amphetamines, can cross the placental fetal blood barrier.
    • Infants born to mothers who used MDMA during pregnancy are at increased risk of congenital birth defects. Prospective follow-up studies of 136 babies exposed to ecstasy in utero indicated that the drug may be associated with a significantly increased risk of congenital defects (15.4%). Cardiovascular anomalies (26 per 1000 live births) and musculoskeletal anomalies (38 per 1000 live births) were predominant.6
  • Acidification of the urine no longer is recommended for amphetamine toxicity. An increased risk of acute renal failure exists secondary to the precipitation of ferrihemate in the renal tubules.
 


More on Toxicity, MDMA

Overview: Toxicity, MDMA
Differential Diagnoses & Workup: Toxicity, MDMA
Treatment & Medication: Toxicity, MDMA
Follow-up: Toxicity, MDMA
References
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References

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Further Reading

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Keywords

MDMA toxicity, MDMA, MDMA intoxication, MDMA overdose, ecstasy overdose, ecstasy, XTC, 3,4-methylenedioxymethamphetamine,amphetamine derivative, psychoactive drug, euphoria, 3,4-methylenedioxyamphetamine, MDA, hallucinogenic amphetamine, rave drugs

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Contributor Information and Disclosures

Author

In-Hei Hahn, MD, FACEP, Attending Physician, Department of Emergency Medicine, St Lukes-Roosevelt Hospital Center; Assistant Clinical Professor, Department of Medicine, University Hospital of Columbia, University College of Physicians and Surgeons.
In-Hei Hahn, MD, FACEP is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Emergency Physicians, and American College of Medical Toxicology
Disclosure: Nothing to disclose.

Coauthor(s)

David Yew, MD, Assistant Clinical Professor, Department of Surgery, University of Hawaii; Medical Director and Flight Physician, AirMed Hawaii/AirMed International
David Yew, MD is a member of the following medical societies: Air Medical Physician Association, American Academy of Emergency Medicine, and American College of Emergency Physicians
Disclosure: Nothing to disclose.

Medical Editor

Peter MC DeBlieux, MD, Professor of Clinical Medicine and Pediatrics, Section of Pulmonary and Critical Care Medicine, Program Director, Department of Emergency Medicine, Louisiana State University Health Sciences Center
Peter MC DeBlieux, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Radiological Society of North America, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

John G Benitez, MD, MPH, FACMT, FACPM, FAAEM, Associate Professor, Department of Medicine, Clinical Pharmacology Division, Vanderbilt University; Managing Director, Tennessee Poison Center
John G Benitez, MD, MPH, FACMT, FACPM, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Medical Toxicology, American College of Preventive Medicine, Society for Academic Emergency Medicine, Undersea and Hyperbaric Medical Society, and Wilderness Medical Society
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Asim Tarabar, MD, Assistant Professor, Department of Surgery, Section of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital
Disclosure: Nothing to disclose.

 
 
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