MDMA (Ecstasy, Molly) Intoxication
INTRODUCTION
MDMA (3,4-methylenedioxymethamphetamine) เป็น synthetic sympathomimetic amphetamine ที่มีฤทธิ์
serotonergic เด่น ต่างจาก amphetamine
ทั่วไป
ผลเด่น: euphoria, empathy, intimacy, disinhibition
พบการใช้มากใน dance club / music festival และมักเป็น polysubstance use
จุดสำคัญทางคลินิก:
toxicity ของ MDMA ≠ amphetamine อย่างเดียว เพราะมี serotonin-mediated toxicity และ SIADH
EPIDEMIOLOGY
- การใช้ขึ้นลงตามยุค แต่ MDMA-related deaths เพิ่มขึ้นตั้งแต่ ~2013
- มักใช้ร่วมกับ ethanol, cocaine, amphetamines
- สารที่ขายเป็น “MDMA” อาจเป็น MDMA
congeners, synthetic cathinones, hallucinogens หรือ fentanyl
PHARMACOLOGY & TOXICITY
Mechanism
- ↑ release + ↓ reuptake ของ
NE, DA
- ↑↑ serotonin (5-HT) → empathogenic effects
- → serotonin syndrome,
SIADH, hyperthermia
Key distinctions from amphetamine
- มี serotonergic toxicity
- เสี่ยง hyponatremia และ hyperthermia
สูงกว่า
KINETICS
- Route:
oral tablet (50–200 mg)
- Onset:
~30–60 min
- Peak:
≤2
h
- Duration:
4–6 h
- Elimination:
~75% excreted unchanged in urine
- Metabolism:
CYP2D6
Severe toxicity can occur after a single tablet
CLINICAL FEATURES
Common
- agitation,
anxiety
- tachycardia,
hypertension
- diaphoresis,
bruxism, nausea
- mydriasis
Life-threatening complications
1.
Hyperthermia
o CNS
stimulation + exertion + environment
o → rhabdomyolysis, DIC, AKI
2.
Hyponatremia (SIADH + water intoxication)
o Na⁺
often <120 mEq/L
o → seizure, cerebral edema,
herniation
o young
women at higher risk
3.
Cardiovascular
o hypertensive
emergency
o MI,
dysrhythmia, aortic dissection
4.
Neurologic
o delirium,
seizure, status epilepticus
5.
Hepatotoxicity
o acute
hepatitis, centrilobular necrosis
6.
Serotonin syndrome
o especially
with SSRI, MAOI, other serotonergic drugs
DIFFERENTIAL DIAGNOSIS
- Other
sympathomimetics: cocaine, amphetamine, methamphetamine
- Anticholinergic
toxicity (dry skin vs MDMA = diaphoretic)
- Metabolic
/ CNS causes: hypoglycemia, electrolyte disorders, ICH, CNS infection
LABORATORY EVALUATION
All poisoned patients
- POC
glucose
- Acetaminophen,
salicylate
- ECG
- Pregnancy
test
Suspected significant MDMA toxicity
- Electrolytes
(+ serum osmolality if hyponatremia)
- CK,
urine myoglobin
- Creatinine
- AST/ALT,
bilirubin
- Coagulation
profile (DIC)
Do NOT rely on MDMA-specific drug screens
→ false negatives
(congeners)
→ false positives
Management is clinical
MANAGEMENT (ED / ICU oriented)
General
- ABCs
first
- Benzodiazepines
= cornerstone therapy
Airway
- Intubate
if ↓ consciousness
(eg, hyponatremia-related obtundation)
Circulation
- Hypertension/agitation
→ benzodiazepines first-line - Refractory
HTN:
- nitroprusside
/ phentolamine
- nicardipine
acceptable
- Avoid
pure beta-blockers
- labetalol
only if unavoidable
Agitation
- Benzodiazepines
(lorazepam IV)
- Avoid
haloperidol/droperidol (↓
heat dissipation, QTc, seizure risk)
Hyperthermia
- Core
temperature monitoring
- Severe
(>41°C): ice bath immersion
- Moderate:
cooling blanket, mist + fan
- If
serotonin syndrome suspected:
- benzodiazepines
± cyproheptadine
- refractory
→ intubation +
paralysis
Hyponatremia
- Mild/asymptomatic
→ fluid restriction
- Severe
neurologic symptoms:
- 3%
hypertonic saline 100 mL IV bolus
- repeat
q10 min × 2–3 if needed
- Acute
MDMA-associated hyponatremia →
low ODS risk
Seizures
- Benzodiazepines
- Correct
hyponatremia if present
- Avoid
phenytoin
DISPOSITION
- ICU:
hyperthermia, severe hyponatremia, cardiotoxicity, serotonin syndrome, severe neuro symptoms - Discharge:
mild symptoms only, resolve within 6–8 h, no end-organ injury
KEY TAKE-HOME POINTS
- MDMA
= sympathomimetic + serotonergic drug
- Think
hyperthermia + hyponatremia + serotonin syndrome
- Benzodiazepines,
cooling, hypertonic saline save lives
- Drug
screen ≠ diagnosis
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