Death and paramethoxyamphetamine — an evolving problem

DEATH FROM AMPHETAMINE USE is a well recognised occurrence, with most reported fatalities involving the use of 3,4-methylenedioxymethamphetamine (MDMA, or “ecstasy”). In 1998, a series of six cases of death due to an unusual amphetamine drug, paramethoxyamphetamine (PMA), was reported in South Australia.1 The only other comparable report of deaths due to PMA was that of nine deaths in Ontario, Canada, in the early 1970s.2 In 1998, our group warned that, although PMA substitution for MDMA appeared at the time to be a local Australian problem, there was a possibility that the manufacture and sale of PMA could occur in other countries. Unfortunately, this prediction has been proved accurate, with recent reports of PMArelated deaths in the United States, Europe and Canada.3-5 Initially, it was assumed that PMA was created as a contaminant during the synthesis of MDMA and was being disguised and substituted for MDMA by local dealers attempting to offload the drug.1,6,7 However, this is now considered unlikely, as the chemical precursors of PMA and MDMA are different,3,4 and information received concerning Case 3 (described here) suggests that capsules containing only PMA are being marketed specifically to augment the effects of MDMA. This is an extremely dangerous development, as it is well recognised that PMA has a much greater propensity to produce adverse effects than other ring-derivative amphetamines.6 Death in each of the cases described here was due to PMA toxicity with hyperthermia. PMA levels of higher than 0.3 mg/L and MDMA levels higher than 0.6 mg/L have been found in cases where deaths were attributed to these drugs.1 Roger W Byard,* Nicholas G Rodgers,† Ross A James,‡ Chris Kostakis,§ Andrew M Camilleri§