Over the weekend, my attention was drawn to a column by National Poisons Centre toxicologist Leo Schep, published in the Herald last week, apparently in response to comments by Wellington ED doctor Paul Quigley, calling for regulated sale of MDMA.
The reasons Quigley might favour such a course are outlined in my what's-in-the-pills story for the New Zealand Drug Foundation's Matters of Substance magazine, which sparked the current media interest in the topic.
Essentially, MDMA (it would be nice if the news media could stop referring to "the purest form of Ecstasy") is less risky than most of the other chemicals people might find in a pill they have bought in the belief it contains MDMA.
Schep strongly disagrees, and opens his column with probably the most alarming case he could cite in support of his argument:
In May 2010, 12 people attending a rave party at a venue called the Cow Palace in Daly City, California, experienced life-threatening complications requiring immediate medical attention; symptoms included seizures and hyperthermia with resultant muscle breakdown and kidney failure.
Two died and four had permanent brain and muscle damage and/or kidney injury. Blood samples from those affected and confiscated tablets from the event identified Ecstasy without evidence of other recreational drugs.
It's tempting to suppose that there was something else at play here. The emergency presentations were so dramatic that both doctors and police initially told news media they suspected the pills taken by the patients had been contaminated with a toxic substance.
But Schep is correct. The case series documented in the wake of the admissions notes that:
The analyzed patient serum, urine, and confiscated pills as well as autopsy reports confirmed MDMA as the sole intoxicant
Only three of the 12 patients (including one who died) were subject to blood tests. There is no evidence as to whether they, or any of the other patients, took the same pills or capsules. The analyses of the separately confiscated pills – two from an event attended by 16,000 people – are irrelevant in all but one respect, which I'll get to in a moment.
What all 12 had in common was hyperthermia – severely elevated body temperature. The group that suffered suffered "severe morbidity" presented with the highest temperatures – a mean of 41.6C – while the "intact survival" group presented with a mean temperature of 39.3C. The fulminant organ failure and other effects described in these cases are consistent with hyperthermia.
The authors observe:
There are several potential explanations for the poor clinical outcomes in our case series: the victims’ presenting core temperatures; the duration of hyperthermia; the treatment methods used for hyperthermia; the large amounts of MDMA in pills; and in some cases, prolonged hypoxia. Surviving patients commented that the indoor venue was unusually warm that evening. High ambient temperatures combined with prolonged highenergy dancing, seizures described in some cases, and the metabolic effects of MDMA account for the hyperthermia seen in 10 of 12 patients. Most of the severe morbidity and mortality in these cases can be attributed to hyperthermia effects.
Rave enviroments are often "unusually warm" without producing the disastrous cluster of cases seen in 2010. So what happened? Perhaps some of the nine patients whose blood was not tested took something unexpected and toxic. Perhaps it was simply incredibly bad luck that it all happened on one night.
As the authors note, "[t]his case series represents the most severe clinical outcomes reported due to MDMA toxicity from a single event" and "[m]ass casualty events due to MDMA are rare." The only case they cite as a comparison is actually quite different: nearly all the patients then were checked and sent home and the sole patient who died suffered a "multidrug overdose of MDMA, cocaine, and heroin."
But let's go back to those confiscated pills. The potency of the first is not noted, but the second contained 270mg of MDMA. That's as much as three times a typical dose.
There's an easy comparison with another popular recreational drug here. If you drink two bottles of wine in a night, you will very likely suffer a nasty hangover. If you drink two bottles of spirits (which contain about three times as much alcohol as the wine) you might well wind up dead of alcohol poisoning.
From what I can tell, the serum blood analyses of the three patients are consistent with very high doses of MDMA. Welcome to one of the other problems of illcit drug supply: not only is there no control over purity, potency is also uncontrolled. This is an effect of the system Schep is emphatic should be maintained. He is effectively arguing against the evidence he presents.
MDMA is not harmless, as the case Schep describes makes clear. It can be deadly. But it's not hard to see why emergency doctors like Quigley would see it as a better option than most other things that could turn up in a pill: globally, MDMA accounts for only a small proportion of emergency visits and a large percentage of those are not life-threatening.
I'm not pretending that the legalisation and regulation of MDMA would be easy or uncomplicated – and indeed, I wouldn't expect to see it any time soon. But even a degree of realism would make way for safer dancing environments and a higher degree of certainty as to what's actually being taken. Leo Schep's prescription, on the other hand, is a recipe for more of the same thing that killed those poor people in 2010.