Ecstasy

Ecstasy, or 3,4-methylenedioxymethamphetamine, is an amphetamine derivative that has been used as a recreational drug since the mid-1980s, especially in connection with rave parties. This drug acts by affecting how neurotransmitters send signals in the brain that produce feelings of euphoria and well-being. When taken recreationally in settings such as rave parties, ecstasy is used to ‘enhance the vibe’, taking advantage of the effects of the drug on mood. Ecstasy is well absorbed when taken orally and works quickly. Although the majority of people who take ecstasy do so without undesirable effects, there are serious complications associated with the use of ecstasy. Common short term problems include tachycardia, sweating, muscle spasms and extremely high fever (38.5°C to 43°C). In cases of severe toxicity, the patient has a high fever that can progress to rhabdomyolysis, renal failure, seizures, disseminated intravascular coagulopathy, cardiac arrhythmias and death. There have been at least 58 deaths associated with the use of ecstasy over the past eight years worldwide, with six of these death occurring in Canada. There is very limited treatment available for the severe complications of ecstasy toxicity, and this treatment is primarily supportive. Given the prominence of hyperthermia as a component of adverse effects to ecstasy, a course of dantrolene sodium, as used in the therapy of malignant hyperthermia, would be a reasonable therapeutic option. There are some factors common to raves that increase the risk of severe toxicity from ecstasy. These factors include high room temperatures (in excess of 30°C), vigorous activity (such as prolonged periods of dancing) and limited access to water or other beverages, which can lead to dehydration. Additionally, as with any illegal drug, there are concerns about purity, contamination and the possibility that other drugs are being sold as ecstasy. As an example, tablets sold at raves and labelled as ecstasy have been found to contain ketamine, a drug that can be associated with hallucinogenic toxicity, instead of ecstasy. There are some data that suggest that the long term use of ecstasy and similar compounds in animal models leads to significant and apparently permanent changes in neuro-transmitter concentrations in the central nervous system. This effect is very troubling and suggests that the long term use of ecstasy may be associated with long term neurological consequences. There are two considerations for paediatricians. The first relates to the evaluation of patients who may have ingested ecstasy. The acute evaluation of these patients starts with the ABCs — management of airway, breathing and circulation — and evaluation of core body temperature, hydration and renal function. Management includes supportive therapy and the use of dantrolene when hyperthermia is present. It is important that the paediatrician recognizes the possibility of exposures to other drugs and the possibility of issues such as sexual assault. Patients should be monitored closely in an appropriate facility until they are stable, and the paediatrician is encouraged to make use of regional resources such as poison control centres. The second consideration relates to harm reduction, notably counselling and risk reduction for adolescents. All adolescents who plan to attend a rave should be aware of these risk factors. Strategies to reduce the risks include ensuring that adolescents know the risks associated with the use of drugs such as ecstasy, that they know what some of the warning signs of toxicity are (high fever, very rapid heart rate), that they are aware of the risks of contamination of drugs with other drugs, and that they take frequent breaks and ensure that they drink water or other nonalcoholic beverages frequently. As well, teens that attend a rave party should not attend alone; they should take a friend with them so that they can look out for each other. These problems point to the importance of adolescents understanding the potential dangers that can occur when drugs such as ecstasy are used. The best treatment for the problems associated with ecstasy is prevention. Physicians and parents should discuss issues, such as drug use and attendance at rave parties, with their teens in an open and nonjudgemental manner. The emphasis of these conversations should be on how to avoid harm and reduce risk. Parents, physicians and groups such as the Canadian Paediatric Society are concerned about risks related to the use of drugs such as ecstasy by teens. In the shared goal of safety for teens, information is the best weapon.

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