E for Ecstasy by Nicholas Saunders
Appendix 1: Reference Section

51 Toxicity and deaths from MDMA from The Lancet by John Henry et al. August 1992

A report of toxicity and fatalities related to MDMA use picked up through a search of enquirers to the National Poisons Information Service in London and encountered directly by doctors at the National Poisons Unit at Guy's Hospital, London during 1990 and 1991.

There was a striking increase in the number of calls to the NPIS related to Ecstasy use. What was being sold as E usually contained MDMA but MDA and amphetamine were also found; mixtures were uncommon. Henry et al. say that co-ingeston of MDA with MDMA cannot be excluded by analysis of biological samples and that the pattern of toxicity did not seem to be a result of overdose. One analytically documented overdose showing plasma MDMA 7.72fmg/l - allegedly 42 tablets - resulted only in a "hangover" with tachycardia and hypertension.

Reports from the USA suggested MDMA was only mildly toxic. The main cause of death was cardiac arrhythmias; rhabdomyolysis and disseminated intravascular coagulation (DIC). Most cases the authors were consulted about had mild symptoms. There was a clear pattern of toxicity in the most severe cases. Death was probably due to heatstroke "in which severe hypothermia was accompanied by DIC". There was no evidence of drug impurity being responsible for toxicity. All fatalities occurred after the user had been at a crowded party or club. Sustained physical activity, high ambient temp, inadequate fluid replacement could all reduce heat loss and the direct effect of the drug may upset the thermoregulatory mechanism. The authors conclude that MDMA is capable of causing severe toxicity and that the pattern of acute toxicity witnessed in the series of cases studied may be due mainly to the circumstances in which it is misused.