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An MDMA cluster and the utility of illicit drug blood sampling

Illicit drugs are involved in 7% of emergency department (ED) presentations, however the identification and measurement of blood concentrations is unavailable to the emergency physician [1]. Relying on clinical impressions can be inaccurate affecting further diagnostic evaluation and treatment in these patients. An approach based on the Western Australian Illicit Substance Evaluation (WISE) study developed at our hospital, overcomes this through the collection, storage and analysis of blood samples using Liquid Chromatography-Quadrupole-Mass Spectrometry [2]. If a clinician suspects that a patient has taken an illicit drug, then a blood sample can be collected. Knowledge of the causative agent in the clinical context may allow management to be tailored, particularly in life threatening ingestions and clusters (defined as aggregation of cases close in time and place) of poisoning. A cluster of patients with suspected 3, 4-methylenedioxymethamphetamine (MDMA) poisoning illustrates the value of blood testing to detect or exclude illicit drugs as a cause of the patient’s presentation. A cluster of six patients presented with suspected illicit drug intoxication to the ED of Royal Perth Hospital over 4 h in 2019. Many patients exhibited agitated delirium, sweating, tachycardia, dilated pupils, and abnormal movements suggestive of sympathomimetic toxicity. All patients received symptomatic care for sympathomimetic toxicity including IV fluids and benzodiazepines. Blood samples were sent to WA ChemCentre Forensic Laboratories for analysis against a database of approximately 500 illicit and novel psychoactive compounds. Results were available within 29 h of sample receipt (Table 1). MDMA was detected in four patients, with median plasma MDMA concentrations 0.29mg/L (IQR, 0.10–0.57). In those patients all were discharged from hospital by 24 h. However one of these patients ( ) presented with status epilepticus requiring intubation and admission to ICU that was attributed to MDMA intoxication. This assumption was refuted at 29 h when no illicit drugs were detected in her blood analysis thus prompting ongoing investigations (MRI brain, EEG, lumbar puncture, vasculitic and autoimmune screens), looking for alternate causes for their seizure disorder. There is currently limited information relating MDMA plasma concentrations to clinical effects in recreational users. The Australian National Coronial Information System reports a median MDMA concentration of 0.45mg/L between 2001 and 2018 and was significantly higher amongst females than males (0.70 vs. 0.42mg/L). Deaths attributed solely to MDMA toxicity had higher blood MDMA concentration than deaths attributed to multiple drugs (1.20 vs. 0.43mg/L) [3]. The patients in this cluster had median plasma MDMA concentrations of 0.29mg/L. This cluster highlights that despite similar patient presentations in close proximity in location and time, the inference of these associations can lead to medical bias. Blood collection, storage and analysis helps refine clinical decisions and management. In the most severely unwell patient, the absence of illicit drugs on analysis changed the direction of clinical management. While results currently take 24 h, advances in analysis and wider availability of assays for illicit substances have the potential to improve the timeliness of clinical care and reduce clinical bias. This cluster also noted that plasma MDMA concentrations were at median levels as previously reported in coronial literature.