“Overview of amphetamine-type stimulant deaths in the UK – critical review and commentary.” By Ilsa Jerome, Ph.D.
Despite news generated by a new study authored by Schifano and colleagues, ecstasy is not especially deadly in younger people.
By Ilsa Jerome
Recently the news media have picked up on a report published in the journal Neuropsychobiology comparing deaths associated with amphetamine with ecstasy-related deaths, spawning news reports with headlines such as “Ecstasy Especially Deadly for Young Users”, wherein the study’s first author, Fabrizio Schifano, is quoted as saying, “that ecstasy seemed to have a higher “intrinsic toxicity,” particularly among users ages 16-24.”
However, upon examination of the report itself, including the abstract and the paper, this conclusion is not warranted. In fact, the paper does not provide sufficient evidence to make declarations about toxicity in general, and the evidence it does supply does not suggest that ecstasy is especially toxic to younger people. Instead, it restricts itself to discussing deaths due to ecstasy and amphetamines, and the comparisons find that overall, amphetamines were associated with a greater number of deaths.
Schifano F, Corkery J, Naidoo V, Oyefeso A, Ghodse H (2010) Overview of Amphetamine-Type Stimulant Mortality Data – UK, 1997-2007. Neuropsychobiology 61: 122-130
ABSTRACT: Background/Aims: Despite being amphetamine derivatives, MDMA and its analogues show a number of clinical pharmacological differences with respect to both amphetamine (AMP) and methylamphetamine (METH). We aimed here at reporting and analysing information relating to the socio-demographics and clinical circumstances of the AMP-type stimulant-related deaths for the whole of the UK. Methods: Data (1997-2007) were taken from the National Programme on Substance Abuse Deaths (np-SAD) database, collecting information from UK coroners/procurators fiscal. To calculate rates of fatalities per 100,000 users, appropriate AMP/METH and ecstasy users’ numbers were taken from the 2001-2007 British Crime Survey. Results: Overall, 832 AMP/METH- and 605 ecstasy (mostly MDMA and methylenedioxyamphetamine/MDA)-related deaths were respectively identified. In comparison with AMP/METH victims, the ecstasy ones were more likely to be younger (28.3 vs. 32.7 years; p < 0.0001) and less likely to be known as drug users (PR = 1.9; CI 1.5-2.6). Ecstasy was more likely to be identified on its own than AMP/METH (p = 0.0192). Contributory factors were more frequently mentioned by coroners in the 'AMP/METH-only' (106 cases) group than in the 'ecstasy-only' (104 cases) one (p = 0.0043). Both poly- and monodrug AMP/METH fatalities per 100,000 16- to 59-year-old users were significantly more represented than ecstasy fatalities (respectively 17.87 +/- 4.77 deaths vs. 10.89 +/- 1.27; p = 0.000; 2.09 +/- 0.88 vs. 1.75 +/- 0.56; p = 0.0096). However, mono-intoxication ecstasy fatalities per 100,000 16- to 24-year-old users were significantly more represented than AMP/METH fatalities (1.67 +/- 0.52 vs. 0.8 +/- 0.65; p = 0.0007). Conclusion: With respect to AMP/METH, ecstasy was here more typically identified in victims who were young, healthy, and less likely to be known as drug users. AMP/METH high mortality rates may be explained by users' high levels of physical co-morbidity; excess ecstasy-related fatality rates in young users may be a reason for concern. Although the coroners' response rate was of 90-95%, study limitations include both reporting inconsistency over time and lack of routine information on drug intake levels prior to death.
This report details data drawn from a national database recording substance-abuse deaths in the UK (the National Programme on Substance Abuse Deaths, or n-SAD). It is notable that the report provides no indication as to how the database determines a death to be “drug related.” It appears that in some cases, detection of a substance in or on the person is used, but it is not apparently necessary. This is especially evident when considering that nearly a fourth of the “ecstasy related” deaths are associated with MDA, and not MDMA (117 of 605 deaths over a ten year period) and one death due to PMA. This paper does not compare ecstasy-related fatalities to fatalities from any other substance save amphetamine, and hence dose not permit blanket statements about the risks of ecstasy, only in relation to amphetamine. It is likely that deaths due to other substances, as opiates, are going to be higher than deaths associated with either ecstasy or amphetamines.
Setting the issue of definition aside, the authors state in the abstract that the total number of deaths related to amphetamines is greater than the deaths related to ecstasy when examining the entire population of people aged 16-59. Examining data from Table 1 of the paper, it is clear that a greater number of deaths involved more than one drug, with approximately 5/6 of the ecstasy-realted deaths involving at least one other substance, including alcohol. It appears that only by selecting a very specific slice of data (deaths apparently related to a single drug in people aged 16-24) that they can make statements about ecstasy-related deaths being higher than amphetamine-related deaths. This is hardly the same as saying that ecstasy is more dangerous to young people than amphetamine.
Perhaps unsurprisingly, a large percentage of drug-related fatalities occurred in known drug addicts. Though it is unclear how the n-SAD database established this information, the UK also has a database recording information on people receiving treatment for substance abuse, the National Drug Treatment Monitoring System. Coroners or others may have had access to this information that would flag these individuals because they were already known to the criminal justice or drug abuse treatment systems. Ninety-one (91%) of the 832 amphetamine-related deaths and 86% of the 605 ecstasy-related deaths occurred in “known drug addicts.” It may well be true that ecstasy-related deaths are less likely to have occurred in known drug addicts, but how significant can this be when over 80% of both types of fatality did, in fact, take place in known drug addicts?
The authors also present percentages of drug related deaths per 100,000 users in Tables 5 and 6, devided by age group. Here we learn that an estimated 6.85 deaths occurred per 100,000 users aged 16 to 24 over the ten year period, and 6.62 deaths per 100,000 ecstasy users, and when a death is solely attributed to a single substance, 0.8 deaths per 100,000 are attributed to amphetamines and 1.67 are solely attributed to ecstasy. While this may be a statistically significant difference, in all cases these estimated death rates are low and not at all suggestive that ecstasy is “intrinsically toxic.” What’s more, by subtracting sole use deaths from total estimated deaths, it is still the case that polysubstance use accounts for a greater number of deaths in either population (6.05 for amphetamine-related deaths, 4.95 for ecstasy-related deaths).
It is notable that in the US, the death rate for people aged 16-24 is about 1 in 1000, and so an activity that produces a death rate of less than 1 per 100,000 engaged in the activity every year does not seem especially alarming.
By relying on fatalities only, it is hard to assess the circumstances that led to these deaths. If present, this information might shed more light on these statistics. Specifically, it seems likely that younger ecstasy users might behave differently from older ecstasy users or younger amphetamine users. Knowing this information might also help in assessing the significance of ecstasy users being more likely to be “healthy.” After all, if patterns of drug use make it more likely that amphetamine users will be unhealthy, this could not lead one to conclude that ecstasy is more lethal to “healthy people,” but that amphetamine use is associated with being less healthy.
As an additional note, fatalities are a poor indicator of drug toxicity, since substances can produce toxic effects without producing death, and death can results from an interplay between substance, setting and individual characteristics. It is dramatic and easily read, but that doesn’t make fatality the best indicator of toxicity, only the one that requires the least effort to explain or the most attention-grabbing one. This is true whether one is considering substances or any other agent. Nonetheless, this should be kept in mind when viewing the data.
In conclusion, it appears that the authors are determined to wring some bad news about ecstasy from this data, but that they can only do so by selectively attending to specific sub-samples contained within the overall sample of deaths. It does not support the claim that ecstasy use is especially dangerous for younger people nor that ecstasy is intrinsically toxic.
This review would not have been as well-written or informative without the insights of two anonymous colleagues who took the time to comb through the report.