AIMS: To determine trends in 3,4 methylenedioxymethamphetamine (MDMA)-related death rates across Australia, Finland, Portugal and Turkey and to analyse causes of death across countries; and 3. analyse the toxicology of deaths across countries. DESIGN: Analysis of MDMA-related deaths extracted from a national coronial database in Australia (2001-2019) and national forensic toxicology databases in Finland (2001-2017), Portugal (2008-2019) and Turkey (2007-2017). Presentation of MDMA use and seizure data (market indicators). SETTING: Australia, Finland, Portugal and Turkey. CASES: All deaths in which MDMA was considered by the forensic pathologist to be contributory to death. MEASUREMENTS: Information collected on cause and circumstances of death, demographics, and toxicology. FINDINGS: 1,400 MDMA-related deaths were identified in Turkey, 507 in Australia, 100 in Finland, and 45 in Portugal. The median age ranged from 24 to 27.5 years and males represented between 81 and 95% of the deaths across countries. Standardised mortality rates significantly increased across all four countries from 2011-2017, during a period of increased purity and availability of MDMA. The underlying cause of death was predominantly due to drug toxicity in Australia (n=309, 61%), Finland (n=70, 70%) and Turkey (n=840, 60%), and other causes in Portugal (n=25, 56%). Minorities of all deaths across the countries were due to MDMA toxicity alone (13-25%). These deaths had a significantly higher blood MDMA concentration than multiple drug toxicity deaths in Australia, Finland and Turkey. Drugs other than MDMA commonly detected were stimulants (including cocaine, amphetamine and methamphetamine) (Australia 52% and Finland 61%) and alcohol (Australia 46% and Portugal 49%). In addition to MDMA toxicity, benzodiazepines (81%) and opioids (64%) were commonly identified in these deaths in Finland. In comparison, synthetic cannabinoids (15%) and cannabis (14%) were present in a minority of deaths in Turkey. CONCLUSIONS: Deaths related to 3,4 methylenedioxymethamphetamine (MDMA) increased in Australia, Finland, Portugal and Turkey between 2011 and 2017. MDMA toxicity alone can be fatal but multiple drug toxicity remains more prevalent.
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