Drug Abuse

Introduction
PMA has been listed as a controlled drug in the UN Convention Schedule since 1986. It first appeared on the illicit drug market between 1972 and 1973 in the USA and Canada and was usually sold as ‘ecstasy’. It acquired the street name ‘death’ because of its link to at least nine deaths (Cimbura, 1974; Stafford, 1992; Shulgin and Shulgin, 1991). In the second half of the 1990s, PMA was identified as causing at least six deaths in Australia (Felgate et al., 1998; Byard et al., 1998). PMMA appeared in Europe in 2000, and the epidemiological evidence is closely linked to that of PMA because, with the exception of Spain, PMMA has always been found combined with PMA in tablets sold as ‘ecstasy’. The CAM in the Netherlands conducted a risk assessment of PMA and PMMA combined on 5 October 2001 (Reitox national reports).

The epidemiological evidence presented here regarding the public health risks of PMMA/PMA, is based on information collected from:

i. Reitox national focal points in 15 EU Member States
ii. Europol report
iii. Published social science and medical literature
iv. The Internet (English language searches)
v. Youth and mass media (English language searches)

Numbers from the list above are used in the text to code the sources of information.

The availability and quality of the product on the market

Availability at the consumer level (i and ii)

In Europe, there appears to be no evident consumer market for either PMA or PMMA. PMMA was first identified by the laboratory analysis of tablets and body fluids in 2000. It has always been found together with PMA, with the exception of one report from the Spanish national focal point. With regard to large seizures, four Member States (Denmark, Germany, Austria and Sweden) reported nine large seizures of PMMA together with PMA in tablets consumed as ‘ecstasy’ between June 2000 and July 2001. The Netherlands reported three large seizures of tablets containing PMA with MDMA or MDA and two seizures of tablets containing PMA without MDMA or MDA. With regard to small seizures, ‘ecstasy’ tablets containing PMA and/or PMMA have been reported in eight Member States (Belgium, Germany, Spain, France, the Netherlands, Austria, Sweden and the UK) as well as in Norway and Poland.

The ‘Mitsubishi’, ‘Jumbo’ or ‘E’ logo are the most common logos found on tablets containing PMMA/PMA. Other tablets containing PMA, but no PMMA, have carried ‘Mitsubishi’, ‘Elephant’, ‘Nike’, ‘Superman’, and ‘xTc’ logos.

Recent laboratory analyses of tablets sold as ‘ecstasy’ from law enforcement seizures, or pill-testing projects, show that MDMA is the most common substance found in tablets sold as ‘ecstasy’. For example, in the Netherlands in 1999, 86 % of analysed tablets sold as ‘ecstasy’ contained MDMA (EMCDDA, 2001c). The MDMA content, however, is variable ranging from less than 30 mg to over 120 mg.

The availability of ‘ecstasy’ testing kits sold commercially on the Internet indicates a demand for better knowledge about the contents of tablets, although this demand may be largely from dealers. In September 2001, the ‘E-Ztest’ web site began to sell a new colour change test that claims to detect PMA, but not PMMA, at a cost of EUR 35. The ‘E-Ztest’ site warns ‘ecstasy’ users against PMA and gives detailed description of expected colour changes related to primary or secondary amines. The site claims high levels of sales, and offers information in different languages and currencies, with discrete mailing. The ‘E-Ztest’ site claims it has been selling tests kits for three years to more than 100 different countries (). The site links to a ‘pill reports’ site and publishes a ‘subjective’ list of pill content reports from North America, Europe and Australia. According to this list, in September 2001, out of 100 different ‘ecstasy’ tablet reports, only one tablet was being marketed with a ‘PMA’ logo. This ‘PMA’ tablet was identified in Adelaide, suggesting that there may be a small market specifically for PMA in Australia.

Sources at the consumer level (i and ii)

Research among recreational drug users in dance and nightlife settings show that whilst friends are probably the most usual source of ‘ecstasy’, retail dealers and dealer users also operate. In the Netherlands, research has shown that 64 % of 12–18 year-olds purchased ‘ecstasy’ from friends, 15 % in cafes and bars and 35 % from home delivery (Reitox national reports, EMCDDA 2001c).

Trends in availability (i and ii)

Very little information available. PMA first appeared in the USA and Canada in 1972 and PMMA appeared with PMA in the northern European dance scene as ‘ecstasy’ in 2000.

Average dose, degree of variability, purity levels and presence of adulterants (i, ii and iv)

Limited data on content of PMA and PMMA are presented in the pharmacological report, which shows the variability between the tablets containing PMA.

With regard to the reaction of PMA and PMMA to colour change tests, two samples analysed by GC-MS, which identified PMA and PMMA, produced no reaction for the Marquis colour test. They gave a positive result for the nitroprusside colour test and a colour change of purple to brown for the Liebermann colour test (Microgram, 2001). Another report based on tests conducted in the 1960s states that neither PMA nor PMMA give a short-term response (<30 seconds) to Marquis reagent. Like MDMA, PMMA gives the positive blue colour of a secondary amine, while PMA does not elicit a colour (Dal Cason, 2000).

Anecdotal evidence suggests that there is little financial incentive for illicit suppliers in tablets perceived as poor quality.

Other active ingredients (ii)
In the Netherlands, a large number of tablets containing a mixture of PMA and MDMA have been seized (Europol contribution).

Typical prices (i and iv)

Street level prices of ‘ecstasy’ ranged between EUR 6.4 and EUR 25 per tablet (EMCDDA, 2001c). In August 2001, a popular Italian Internet site () provided a narrower range of prices of between EUR 8 and 19, with Amsterdam, Florence, London and Milan all around EUR 15 for one tablet.

Knowledge, perceptions and availability of information

Availability of scientific information (i and iv)

There is considerably more scientific information about PMA than PMMA. Specific information about the dangers of PMA is available in a variety of forms including peer education, outreach work, leaflets, youth media, television, newspapers and the Internet. New information about deaths linked with PMA has rapidly been made available on web sites concerned with illicit drug use and pill testing. For example, in August 2001, the ‘E-Ztest’ site provided early information about deaths linked to PMA in Belgium and provided links to a range of Belgian and Dutch newspaper reports about the deaths ().

Availability of information on effects of product (iv)

Information about the effects of PMA is widely available on Internet sites targeting recreational drug users. Information frequently includes the dangers of taking more than 60 mg and the effect of PMA on raising body temperature ().

Level of awareness of product amongst drug consumers in general (iii)

No evidence available.

Level of knowledge of product, effects and perceptions amongst consumers of product

As there is no market for PMA/PMMA, there is no evidence from deliberate consumers. However, it is worth noting that a study of ‘ecstasy’ users in Northern Ireland showed that consumers of ‘ecstasy’ perceive the brand/logo as a useful means to distinguish between good and bad tablets and believe that the logo helps to identify the specific types of effects that one should expect from a particular brand. Only a few respondents believed otherwise (McElrath and McEvoy, 2001). This belief in the significance of logos exists despite forensic evidence that there is at least some variation in the content found in tablets carrying the same logo and warnings about PMA having been identified in tablets carrying the ‘Mitsubishi’ logo, for example. The Northern Ireland study found that particular brands/logos appeared to produce the same physical or psychological effects for all or most users within a particular friendship or drug-using network in the same setting. Furthermore, ‘ecstasy’ users described a range of pharmacological and social expectations about the effects of the drug. They expect to feel ‘loved up’, ‘sociable’ and ‘confident’ and the way in which those feelings are best manifested is in the user’s interactions with others. In-depth studies such as this demonstrate that the drug’s capacity to deliver is realised through setting and this serves a purpose for illicit producers to use the logos as a marketing device.

Illegality is not an issue for most regular consumers who tend to question the credibility of government and media messages about drugs. Young people tend to obtain information about drugs from other sources, namely through personal experience or from friends and acquaintances. (McElrath and McEvoy 1999; Winstock et al., 2001).

General population

It is unlikely that many people in the general population have heard of either PMA or PMMA.

Television and newspapers are a major source of information about illicit drugs, or a stimulus for discussion among the general public, and newspaper reports of ‘ecstasy’ deaths usually exaggerate the potential for acute damage to health. Consequently, among the general and school age population, ‘ecstasy’ is widely perceived as carrying high risks for health (EMCDDA, 2001c).

Prevalence and patterns of use

In view of the fact that PMA/PMMA is consumed as ‘ecstasy’, the prevalence data for ‘ecstasy’ is relevant (EMCDDA, 2001c). Overall, 0.5–4 % of European adults have tried ‘ecstasy’ and most of this use is concentrated in particular groups with a high affinity for recreational drug use. These figures, viewed in the light of the very limited number of PMA/PMMA seizures (60 in total) compared with 16 000 for ‘ecstasy’ in Europe overall, indicate that prevalence of PMA/PMMA consumption is extremely restricted.

The only other indicators of prevalence are three reports of PMA being detected in urine samples in 2001 (one in Austria and two in Belgium)(Reitox national reports).

Frequency of use (iii)

A large European survey found that only 4 % of young people in recreational nightlife settings took ‘ecstasy’ more than once a week (Calafat et al., 2001). Small proportions of these young people consume several tablets during one episode, at least at some point during their drug career. Although heavy consumption is usually confined to a short period, it is these people who are at the greatest acute and long-term health risks from both MDMA and PMA/PMMA (Korf and Lettnick, 1994; McElrath and McEvoy, 1999). Particular settings invoke more intensive forms of drug use, for example, both the frequency and amount of drugs used tends to increase during holiday periods (Bellis et al., 2000).

Route(s) of administration (i, ii, iii)

PMA/PMMA are usually taken orally, in the form of tablets sold as ‘ecstasy’ (Reitox national focal points and Europol). Following the patterns of using ‘ecstasy’, a tablet containing PMA/PMMA may involve taking an initial dose, followed by a smaller dose after about one and half hours. In the case of MDMA, this is done in order to prolong the positive effects with only a modest exacerbation of the usual physical side effects (Shulgin and Shulgin, 1991).

Other drugs used in combination with the product (iv)

Participants in Internet newsgroups have observed positive effects from mixing PMA with MDMA and negative effects from mixing PMA with alcohol (‘alt.drugs.ecstasy’ newsgroup).

Geographical distribution of use (i and ii)

Evidence about the geographical distribution is very limited but it should be noted that, among the recent deaths, all four that were linked to PMMA occurred in Denmark and in Austria. Seizures of PMA/PMMA, and deaths from PMA, have all occurred in Northern European States (Belgium, Germany, France, the Netherlands, Norway, Sweden, and the UK) with the exception of a national focal point report from Spain (Reitox national focal points and Europol).

Trends in prevalence and patterns of use

Countries such as the UK, Ireland, and the Netherlands may be experiencing a plateau effect with ‘ecstasy’ or even a downturn. Some researchers have noted an increase in the use of a range of substances to augment the positive effects of ‘ecstasy’, known in the Netherlands as the ‘combi-high’ (Nabben and Korf, 2000; Lecesse et al., 2000).

Characteristics and behaviour of users

Age and gender of users (iii)

Evidence suggests that age, and where people live, are more significant than gender in relation to taking ‘ecstasy’ and therefore, inadvertently, to taking PMA/PMMA. However, there is anecdotal evidence that males are more likely to use ‘ecstasy’
excessively and be less concerned about harmful effects than female users (Collison, 1996; McElrath and McEvoy, 1999).

Social groups where product available/used (iii)

Most research on ‘ecstasy’ use has linked it with the techno dance and nightlife scene and linked the sought after effects to appreciation of the music, dance and socialising (EMCDDA, 1997; Calafat et al., 2001).

Risk behaviour associated with use (iii)

The greatest risk behaviour associated with use is taking PMA/PMMA as if it was MDMA. People who take more than one tablet over a short time period are at greatest risk of both acute and long-term health problems from both MDMA and PMA/PMMA.

Special concerns about vulnerable groups (iii)

Special concerns relate to the lack of knowledge both about drug content and about the specific harmful effects of PMA and PMMA. One group of young people who are particularly vulnerable are heavy, excessive, users who belong to groups that are at high risk for a range of problems (Collison, 1996; McElrath and McEvoy, 1999).

Trends in characteristics/behaviours of users (iii)

Research has shown that people tend to use ‘ecstasy’ as long as the positive factors outweigh the negative; the illegality of a drug is not a significant factor among ‘ecstasy’ users (EMCDDA, 2000). A study of ‘ecstasy’ users in Northern Ireland found that the vast majority of respondents reported that they would stop using ‘ecstasy’ if most or all of their friends did (McElrath and McEvoy, 1999).

Indicators of health consequences

Health risks appear to be more closely related to patterns of heavy or frequent use than they are to the drug content of individual tablets.

Hospital emergencies (iii)

In mid-2001, a paper was published in the Medical Journal of Australia describing the clinical features of PMA poisoning (22 cases). It concluded that, in the Royal Adelaide Hospital, PMA poisoning accounted for most of the severe reactions among people who believed they had taken ‘ecstasy’. The authors advised that PMA toxicity should be suspected with severe or atypical reactions to ‘ecstasy’ (Ling et al., 2001). Wide dissemination in Europe of these Australian findings may influence the processes of toxicological analysis in hospital emergencies related to ‘ecstasy’. PMA/PMMA may increasingly be recorded as linked to cases presenting as ‘ecstasy’ intoxication, which previously would have been linked to MDMA.

Deaths (direct and indirect)(i and ii)
Since 1995, PMA has been implicated in at least eight deaths in Australia and 10 in the USA. In Europe, according to the Spanish national focal point, one death in Spain in 1993 was linked to PMMA and another, in 1995, was linked to PMA. Between July 2000 and October 2001, there were ten deaths reported as linked with PMA alone or combined with PMMA in the EU. Three deaths linked to a mixture of PMMA and PMA occurred in Denmark and one occurred in Austria. Six other deaths were reported as linked to PMA and no PMMA, two in Germany and four in Belgium. In at least five deaths, more than one tablet had been taken. In one death, at least six other drugs had also been taken (MDMA, MDA, amphetamine, cannabis, codeine and alcohol; solvents were also suspected) (Reitox national focal points, Table 5).

Initially, a Belgian fatality in February 2001 was recorded as being caused by a toxic concentration of MDMA (0.7 μg/mg) combined with amphetamine. In subsequent investigations, as part of a research project some months later, PMA 1.43 μg/mg was found in blood samples from this person. Subsequent investigations for PMA may have been prompted by heightened awareness of the potential role of PMA in ‘ecstasy’ intoxication.

Traffic accidents

No evidence available.

Requests for treatment/counselling

No evidence available.

Other health indicators

No evidence available.

Context of use

Risk factors linked to circumstances and rituals of consumption

The main risk factor has already been addressed and relates to taking PMA/PMMA unknowingly as if it were MDMA.

Implications for the non-using population (i and iv)

Increasing concern about the possibility of long-term harmful effects of MDMA may make the use of other new synthetic drugs, which are less neurotoxic, an attractive alternative for MDMA. Also, for regular ‘ecstasy’ users who perceive a need to increase the dosage in order to get positive effects with MDMA, combining MDMA with PMA may appear to be an option (‘alt.drugs.ecstasy’ newsgroup).

Fears among the ‘ecstasy’ using population about consuming PMA/PMMA unknowingly may serve to reduce consumption of ‘ecstasy’. However, research shows that when one form of drug consumption is curtailed another frequently replaces it (McElrath and McEvoy, 1999). For example, it has been suggested that there is a growing trend in cocaine use among former ‘ecstasy’ users, as result of their disenchantment with ‘ecstasy’ and fears about long-term neurotoxicity (EMCDDA, 2001c).

< Prev		Next >