Clinical Textbook of Addictive Disorders 3rd ed - R. Frances, S. Miller, A. Mack (Guilford, 2005) WW

168 III. SUBSTANCES OF ABUSEdrug is used in specific settings and by specific subgroups, the level of suspicionshould take into account the user and the circumstance involved. If an individualpatient has been to a rave, or to some club event, this should raise the clinician’ssuspicion that MDMA was ingested. In addition, the clinician shouldhave a high degree of suspicion that the patient may have taken multiple drugs.Drugs that may have been substituted for Ecstasy tablets, such as ephedrine,Ma-Huang (herbal ecstasy), and caffeine, should be considered.Tachycardia, agitation, tremor, mydriasis, and diaphoresis may occur withMDMA intoxication. Ecstasy ingestion may mimic LSD or other classic hallucinogeningestion. In addition, MDMA overdose may mimic the ingestion ofan anticholinergic agent (Shannon, 2000). Anticholinergic agents induce dry,hot skin, however; this result is in contrast to MDMA, which, except in thecase of dehydration, causes diaphoretic skin.Ecstasy overdose would most likely involve the ingestion of multiple dosesand also occur in an environment that induced dehydration. MDMA overdoseor toxic reaction is a diagnosis by exclusion. Supportive measures, such as effectivehydration using intravenous fluids and lowering the temperature of thepatient with cooling blankets or an ice bath, are often necessary. Standard gastriclavage should be employed (Schwartz & Miller, 1997). Physical restraintmay be necessary for agitated patients but should be used sparingly. Benzodiazepinesare the preferred choice as sedating agent (Shannon, 2000). Hypertensionoften resolves with sedation. If it persists, nitroprusside, or a calciumchannelblocker, is preferred over a beta-blocker, which may worsen vasospasmand hypertension (Holland, 2001).Nonurgent TreatmentMDMA ingestion may be associated with a number of adverse psychiatricsymptoms, notably, anxiety, panic, and depression. These symptoms usuallysubside in a matter of hours or days. Support and reassurance are often all that isneeded. If the symptoms are severe, brief pharmacotherapy to alleviate symptomsis recommended.Although classical physiological dependence on MDMA does not occur,some individuals use the drug compulsively. For these people, the standardarray of treatments, based on a thorough assessment of internal and externalresources, should be employed.Adolescents are frequent users of MDMA and the population most likelyto present with this as the drug causing the most problems for them (McDowell& Spitz, 1999). Furthermore, they are more likely to be involved with the subculturethat is enmeshed with MDMA, and that views the drug as harmless atworst, and life-transforming at best (Beck & Rosenbaum, 1994; Winstock et al.,2001). Clinicians are cautioned against adopting a knee-jerk, negative attitudethat may inadvertently preclude the initiation of a therapeutic alliance.