MDMA-related deaths in Australia 2000 to 2018.
MDMA markets have undergone substantial changes internationally, with increasing manufacture of high purity MDMA recorded. This study examined trends in MDMA-related deaths in Australia, investigating characteristics, circumstances and toxicology of these deaths. Analysis of MDMA-related deaths in Australia between 2001 and 2018, extracted from the National Coronial Information System (NCIS). Deaths were categorized into (1) drug toxicity deaths, where MDMA (with and without other drug) toxicity was considered by the coroner to be the underlying cause of death and (2) other cause deaths, with MDMA (with and without other drug) intoxicationtoxicity considered contributory to death. 392 deaths were identified, with a median age of 26 years. 81% were male. Females were significantly younger than males (24 vs. 27 years). Two-thirds (62%) of deaths were attributed to drug toxicity (48% multiple drug toxicity and 14% MDMA toxicity alone), and one third (38%) to other causes (predominantly motor vehicle accidents) with MDMA recorded as a contributory factor. Death rates increased significantly between 2001 and 2007, declined between 2008 and 2010, and increased again between 2011 and 2016. Median MDMA concentration was 0.45 mgL, and was significantly higher amongst females than males (0.70 vs. 0.42 mgL). Deaths attributable to MDMA toxicity alone had a significantly higher blood MDMA concentration than multiple drug toxicity deaths (1.20 vs. 0.43 mgL). Deaths occurred predominantly among males in their mid-twenties, with females likely to be significantly younger. Three marked periods of trends in death rates (increases and declines) were observed, consistent with international supply trends. While most deaths were due to multiple drug toxicity, a notable proportion were attributed solely to MDMA toxicity.