Case Studies and Oddities
This section is a
more for historical/human interest than medical information; it tells
the stories of some unlucky (and in some cases, lucky) people who ran
afoul of trouble in the pursuit of a high. The cases chosen for inclusion
are simply ones I find interesting, with no effort made to cover the
range of adverse events documented.
Case 1: "My dealer says there's morphine
in it."
Victim: 24 year old white
male drug dealer, approximately 77 kg. (1979.)[1]
7:30 p.m. Subject was at a party,
where he was witnessed to take a 300 mg tablet of methaqualone (a sedative.)
Fifteen minutes later, he 'parachuted' (swallowed wrapped in tissue
paper) approximately half a gram (500 mg) of what he believed to be
a mixture of LSD, amphetamine, and morphine.
11:00 p.m. Subject took an additional 700 mg of the powder.
An hour later, he was heard to complain that he 'needed rest' and lay
down.
1:00-2:00 a.m. Subject begins to thrash about violently
and is incoherent. In spite of apparently having to be resuscitated
by CPR,
no medical assistance is summoned. Eventually the subject appears
to be improving, and falls asleep.
2:30 a.m. Subject is found completely unresponsive.
An ambulance is summoned, but the victim appears to have been DOA at
the hospital.
Toxicology determined
that the 'drug mix' the victim had consumed well over a gram of was
in fact MDA powder. (MDA is a more potent cousin of MDMA.) Toxicology
reported a blood MDA concentration of 10 ng/ml, about twenty times
what would be expected from a moderate recreational dose. Lesson:
Are you sure your dealer knows what he has and how to use it safely?
Case
2: A shocking turn of events.
Victim: 22 year old male ecstasy user (1987.)[2]
A body is found at the
base of a utility tower (the large metal affairs, not wooden poles.)
The medical examiner reconstructs events based on his examination of
the body, concluding that the victim had climbed the tower to a height
of about 40 feet, where he came into close contact with one of the
138,000-volt high-power lines. It was unclear if the shock or the fall
killed him. Toxicology reports an unknown quantity
of MDMA in his blood; no other drugs or alcohol.
Beyond the strange particulars
of this death, it is extraordinary for having happened at all; MDMA
tends to produce a paranoia of physical dangers. Death by misadventure
is rare, especially in the absence of other drugs (like alcohol.) Unfortunately
it couldn't be determined if the victim was high when he attempted
the climb, but it seems likely that he was; the immediate aftereffects
of MDMA usually involve lethargy/fatigue and a general avoidance of
stimuli.
Case 3: Don't hold your breath.
Victim: 32 year old male ecstasy user (1987.)[2]
Victim was found
dead in his car, with his 0.5% epinephrine inhaler in his hand. The
death was ruled to be due to severe asthma, but toxicology reported
a blood MDMA concentration of 1.1 ng/ml, about twice the level a moderate
recreational dose would be expected to produce.
This seems to be the only
documented case of death involving MDMA and asthma. Although causality
is unclear, it wouldn't be surprising if the high dose of MDMA consumed
was
an aggravating
factor.
Case 4: Looking forward to having a Goodyear.
Patient: 22-year-old male.[3]
The patient was brought
into the Emergency Department, having been injured after repeatedly
leaping into the path of oncoming traffic. Questioning by a psychiatrist
eventually revealed that the young man had been using 'ecstasy' at
a rate of 4-7 times a week for the past four months. During the week
before the incident, he had become increasingly convinced that a group
he had been in a fight with was trying to kill him, and had apparently
decided to deny them the pleasure by doing the job himself. The patient
was treated and released, but came back to the hospital two months
later, reporting that although he had ceased using 'ecstasy', he continued
to have 'flashbacks' (feeling as though he were high on MDMA) and once
again believed he was being persecuted, etc.
Treatment with medication
produced full remission, and medication was withdrawn after four
months. Eight months after the initial incident, he began to use 'ecstasy'
again
and suffered another psychotic break, which he recovered from in about
a week.
Comments: An interesting
case of psychosis developing in the wake of severe amphetamine abuse.
His period of abuse may have sensitized him to further relapses
from even moderate use of MDMA. It has been suggested by some that
MDMA cannot produce psychosis, and under normal conditions of use I
would be inclined to agree. However, with heavy abuse, the effect of
the drug appears to become more amphetamine-like as the less robust
serotonergic system contributes less and less of an effect to the total
'high' and dosages increase.
Case 5: "Surf's up!"
Victim: 26-year-old male idiot (1994). [4]
A young man dies 36 hours
after being brought in to the Emergency Department with a severe head
injury. Toxicology reports 0.63 ng/ml of MDMA (high but not remarkably
so) and a blood alcohol level of 0.123% (drunk, but not staggeringly
so.)
The pathology of injuries was unremarkable, but how he got them was:
At the time his injuries were sustained, he was "car surfing";
standing on top of a car's roof while holding onto ropes coming out
of the
front side windows. During acceleration in a strait section of road,
he lost his balance and fell. Interviews with the guests at the party
he had been at reported that this act had been the culmination of a
series of dares and stunts between a number of young men performing
for a cheering audience of young women at the party.
This story includes all the
classic elements of human stupidity: Young men, women, cars and alcohol.
The addition of MDMA would have further impaired judgment and ability
(balance/coordination.) MDMA makes you impaired but largely aware
of it. Alcohol makes you impaired and largely unaware of it. Combine
the two in generous amounts and you get a whole lot of stupid with
minimal self-awareness of that fact.
Case 6: Should have called a cab.
Victim: 29-year-old white male (1996.)[5]
While driving by himself
down a highway, the man's car veered off the road, rolling down an
embankment and ejecting the driver. The responding ambulance declared
him dead when they arrived. Toxicology screening revealed a blood MDMA
concentration of over 2 ng/ml, about 4 times the peak level produced
by a moderate (1.5 mg/kg) dose. It's no wonder he couldn't drive, although
it's likely the crash would have been survivable if he had been wearing
a seatbelt.
Case 7: Living in the plastic age.
Patients: Five males, one female, ages 17-25 (1997.)[6]
In the days after a
party, young people began trickling into a hospital with severe abdominal
pain and signs of liver damage. Interviews revealed
that they had all consumed a beverage laced with "MDA" at
the party (the "MDA" had been supplied by one of them.) Upon
further questioning, it was learned that the individual who supplied
the "MDA" had discovered
that a local chemical company was selling it and, delighted to find
what he believed was an illegal recreational drug being sold openly
and over-the-counter, had purchased some. Unfortunately for his friends,
he decided to share his new 'stash', offering some to them as well
as taking some of the spiked punch himself. (They were apparently all
aware of this; nobody was 'drugged' unwittingly.) Upon further investigation,
it was discovered that the fortuitous find of a local "MDA" source
was not so fortunate or surprising: The chemical in question was methylene
di-analine, a chemical used in the
manufacture of polyurethane foam...not the desired drug methylenedioxyamphetamine.
All made a full but painful recovery and were presumably wiser for
the experience.
Case 8: It was that or a beating.
Patient: 17-year-old girl (1997.) [10]
The patient presented at
the hospital complaining of chest pain several days after using 'ecstasy'
at a party. X-rays revealed a pneumomediastinum; a bubble
of air settled in the lining around her heart. She made a swift recovery
with
minimal treatment. Interviews with the girl revealed that she had
danced almost continuously for about eight hours while blowing
on a whistle. This repeated overpressurization of the lungs had caused
sufficient damage to the fine blood vessels in them to allow air to
be forced into the bloodstream, where it collected near the heart (and
also in a neck artery.)
This sort of injury is
also sometimes seen in people who smoke drugs due to forcibly holding
in the smoke. My sympathy for the patient is greatly blunted by the
sort of nuisance she apparently made of herself at the party with that
whistle.
Case 9: Suicide solution, attempt 1.
Patient: 30-year-old male (1998.) [7]
A young man is brought
into the hospital after being found unconscious and convulsing, with
a rapid
pulse and elevated body temperature. Aggressive 'stomach pumping' recovered
2.8 grams of MDMA from his stomach. With treatment of the symptoms,
the patient made a full recovery over the next two days, and was released
on the third day. Upon recovery, he told doctors that he had taken
a total of 50 tablets of 'ecstasy', 100 mg of oxazepam (a benzodiazepine
sedative), and five alcoholic beverages in a suicide attempt. Ironically,
it may have been his drug mixing that saved him, the alcohol and oxazepam
partially counteracting the MDMA's stimulant effects. He was also in
a cool, quiet environment which presumably further reduced the severity
of hyperthermic response.
Case 10: Suicide solution, attempt 2.
Patient: 19-year-old-male, weight 75 kg (1999.) [8]
Subject was found confused
at home approximately 12 hours after taking as many as 40
tablets of 'ecstasy.' At the hospital, the patient was sluggish but
responsive and cooperative, showing normal blood pressure, normal body
temp, and moderately elevated pulse. He remembered nothing of the day
leading up to his admittance to the hospital. Blood alcohol of 0.13%.
At 13 hours after taking the pills, his blood serum level of MDMA was
4.3 ng/ml, about 8-10 times the peak a moderate recreational dose would
produce. The patient was treated and rapidly improved; 24-hours after
being brought in, he checked himself out against doctor's advice. When
he left the hospital, his blood MDMA level was still 0.75 ng/ml (comparable
to what a high recreational dose might produce at its peak aprox.
2 hours after ingesting it.)
This case may not
have been a suicide attempt; simple bad judgment may have been to
blame. As before, it's possible that the alcohol reduced the danger
of fatal
heatstroke, but it would be extraordinarily unwise to regard alcohol
as a treatment for MDMA overdose. Death by MDMA overdose strikes me
as a somewhat horrible way to go; just because it's a pleasant high
at low doses doesn't mean it's fun as an overdose.
Case 11: Shattered lives (successful suicide.)
Victim: 53-year-old male Doctor of Psychiatry (1999.)
[9]
The victim was found in
distress in a jail cell eight hours after his arrest for possession
of "marijuana and narcotics." A hand-written will was
found with him. In spite of aggressive emergency treatment, the victim
suffered heatstroke-induced multiple organ failure (reaching a peak
temperature of over 107F.) He died in the hospital five days later,
having never regained consciousness. Toxicology revealed a massive
MDMA overdose; at the autopsy, he still had potentially lethal levels
of
MDMA in his system. The case report doesn't go into the legal details
of the case, but given the timing, the likely scenario is that the
victim had a sizeable quantity of MDMA hidden on him that wasn't found
by the arresting officers. Upon his arrest, facing prison time, the
loss of his medical license, and public humiliation, the doctor apparently
decided that, rather than simply flush the evidence, the only real
option left was to end his life. Why he had the drugs on him is unknown,
but given his medical credentials, it's quite possible that he was
involved in the psychotherapeutic use of
MDMA in his practice (something that continues to this day in spite
of the government ban.)
[1] Poklis A, Mackell MA, Drake WK "Fatal intoxication
from 3,4-methylenedioxyamphetamine" Journal of Forensic Science,
1979; 24(1):70-5. Abstract.
[2] Dowling GP, McDonough ET 3rd, Bost RO "'Eve' and
'Ecstasy'. A report of five deaths associated with the use of MDEA
and MDMA" JAMA, 1987; 257(12):1615-7. Abstract.
[3] Creighton FJ, Black DL, Hyde CE "'Ecstasy' psychosis
and flashbacks" Br J Psychiatry, 1991; 159:713-5. Abstract.
[4] Hooft PJ, van de Voorde HP "Reckless behaviour related
to the use of 3,4-methylenedioxymethamphetamine (ecstasy): apropos
of a fatal accident during car-surfing" Int J Legal Med, 1994; 106(6):328-9.
Abstract.
[5] Crifasi J, Long C "Traffic fatality related to the
use of methylenedioxymethamphetamine" J Forensic Sci, 1996;
41(6):1082-4. Abstract.
[6] Tillmann HL, van Pelt FN, Martz W, Luecke T, Welp
H, Dorries F, Veuskens A, Fischer M, Manns MP "Accidental intoxication
with methylene dianiline p,p'-diaminodiphenylmethane: acute liver damage
after presumed ecstasy consumption" J Toxicol Clin Toxicol,
1997; 35(1):35-40. Abstract.
[7] Ramcharan S, Meenhorst PL, Otten JM, Koks CH, de
Boer D, Maes RA, Beijnen JH "Survival after massive ecstasy overdose"
J Toxicol Clin Toxicol, 1998; 36(7):727-31. Abstract.
[8] Regenthal R, Kruger M, Rudolph K, Trauer H, Preiss
R "Survival after massive 'ecstasy' (MDMA) ingestion" Intensive
Care Med, 1999; 25(6):640-1. Abstract.
[9] Walubo A, Seger D "Fatal multi-organ failure after
suicidal overdose with MDMA, 'ecstasy': case report and review of the
literature" Hum Exp Toxicol , 1999; 18(2):119-25. Abstract.
[10] Pittman JA, Pounsford JC "Spontaneous
pneumomediastinum and Ecstasy abuse" J Accid Emerg Med,
1997; 14(5):335-6. Abstract.
