Drugs and death

Nicole Ann Crowder’s mother should be thinking about her 17-year-old daughter’s upcoming final exams. Instead, she had to say her final goodbyes to her only child, a Yuba City High School junior, who died three weeks ago after taking a tablet of Ecstasy at a party.

Once reports came back showing Ecstasy in Crowder’s system, the mainstream media immediately labeled it a drug overdose, even though tests showed she had consumed just one dose. Doctors and investigators still haven’t determined exactly how she died, nor identified any contributing factors beyond the drug itself.

Left largely undiscussed so far was that fear of drug laws and even the harm reduction efforts of well-meaning friends might have contributed to Crowder’s death. Did fear of punishment prevent her friends from taking Crowder to the hospital? Did the mistaken belief that lots of water would help her actually trigger her death?

Have these possibilities been discounted in the push to make Nicole Crowder the latest poster child for the “drugs equal death” campaign that has recently saturated the airwaves?

It happened at a spring barbecue at a friend’s house on April 26, according to Lt. Bill Oller of the Yuba City Police Department. The parents were out of town, and a couple dozen kids gathered to enjoy the opportunity. Crowder joined them around 9:30 p.m. Instead of her usual outgoing self, however, her friends soon noticed that the girl had curled up quietly on a couch.

She had taken some Ecstasy, she told a friend, but now she wasn’t feeling so good. In fact, she was feeling awful. She had a headache and was sweating copiously. Afraid of dehydration, they gave her lots of water, but it didn’t help. Instead, things got worse: she began to vomit and feel even more sick. Her friends helped her into a spare bedroom, where they left her to sleep off what they thought was just a bad trip.

The next morning, her friends found her unresponsive, and she was declared dead on arrival at the hospital. Her autopsy showed no apparent cause of death, but an expedited drug analysis showed a single dose of Ecstasy in her system.

Crowder certainly wasn’t alone in her decision to indulge in the drug: more than 3.4 million teens and young adults, or 12 percent of her peers, have experimented with Ecstasy in the United States, according to a 1998 National Household Survey on Drug Abuse.

Ecstasy is the common name for 3, 4-methylenedioxymethamphetamine, or MDMA, a semi-synthetic drug patented by Merck Pharmaceuticals in 1914 as an appetite suppressant. Others know it as E, X or the hug drug. In the ’80s, psychotherapists used it to facilitate therapy due to the feelings of empathy and euphoria it gave users.

Ecstasy has been long associated with European-style raves or dance clubs, although in recent years it has migrated into smaller, more intimate gatherings like the Yuba City party. It is often found as a round, light brown, white or pastel-colored 100-200 mg. tablet stamped with a popular cultural icon, animal or commercial logo.

It’s still early in the research game to be making conclusions about how long-term effects will manifest, or how permanent they might be, but one oft-cited study from Johns Hopkins University showed that use of Ecstasy was associated with greater impairment in immediate verbal memory and delayed visual memory, lower vocabulary scores and poorer memory performance.

In 1986, growing recreational use resulted in the U.S. Drug Enforcement Agency criminalizing it as a Schedule I narcotic. (Schedule I narcotics, according to the DEA, have a high potential for abuse and no accepted medical use, and include LSD, heroin and marijuana.)

The Partnership for a Drug-Free America, creators of the fried-egg “this is your brain on drugs” ads of the ’80s, has launched a multimillion-dollar campaign focusing on an Arizona case eerily similar to Crowder’s. “XTC” is a national ad blitz that depicts Ecstasy as a lethal substance, focusing on the death of Danielle Hierd and featuring her grieving mother (view the Web, video and print ads at www.drugfreeamerica.org).

Despite the cautionary power of such appeals, the reality is that Ecstasy alone is rarely fatal. Forty-two Ecstasy-related deaths were reported in 2000, and nearly all of those involved mixing Ecstasy with other drugs. (Compare this to 105,000 alcohol-related deaths, and 365,000 tobacco-related deaths, according to the National Council on Alcohol and Drug Dependency.)

But to run an anti-Ecstasy campaign based upon the very rare deaths is irresponsible, according to Dr. Mark A.R. Kleiman, a professor at the school of public policy and social research at UCLA. “Both alcohol and MDMA can be dangerous drugs, but the risk of acute toxic death is not something I would emphasize if I were trying honestly to convey what the real risks are.”

If death becomes the most regular warning, and young people see their friends doing the drug and not hearing of many deaths, they learn to discount the ads, Kleiman said. “And after that, they discount everything else they hear about the drug.”

When you have millions of people already taking the drug, teaching those people to mitigate the dangers of doing so is important. Kleiman explained: “The right thing to focus on in MDMA use is where people take multiple doses for three nights a weekend every week. Now that’s dangerous!”

Dr. Kleiman isn’t alone in his assessment of the dramatic media portrayal of Ecstasy. At the 2001 National Institute on Drug Abuse conference, reported in JAMA, educators say that the dramatic take-drugs-and-die campaigns are ineffective and need to be replaced with a program that acknowledges the realities of Ecstasy.

“We’ll be better off having a campaign that says ‘Ecstasy can make you feel really good. It increases your sensory awareness, it makes you feel music.’ It’s OK to acknowledge that,” said Claire Sterk, Ph.D., a professor of behavioral sciences at the Rollins School of Public Health in Atlanta, Georgia. “And then have a big comma and say, ‘But there are consequences.’ We know people will continue to use. What we can do right away is come up with appropriate, targeted messages to reduce the risk.”

For the family and friends of Nicole Crowder, the risk of death from Ecstasy is very real. But here too, the alarmist warnings of the “drugs equals death” proponents may have scared Crowder’s friends into taking the wrong actions, and may still be hindering our understanding of what really happened.

Inflated media portrayals haven’t helped. The Sacramento Bee headlined Crowder’s death as an “Ecstasy overdose” in the May 1 edition, although the medical examiner’s report listed the cause of death as “Ecstasy intoxication” and final toxicology reports hadn’t been finished.

“That should have been ‘suspected Ecstasy overdose,’ ” said Lt. Oller of the Yuba City Police. “The truth is, we don’t know and we wouldn’t say that until we see the final medical examiner’s report. The entire toxicology test process could take four to six more weeks.”

Even the preliminary listing of “Ecstasy intoxication” as the cause of death doesn’t explain how Crowder died.

“It’s not intoxication that kills you,” said Dr. Kleiman. “Something has to stop working. For instance, with heroin, the nerve that drives the diaphragm is paralyzed. ‘Intoxication’ is just medicalese for ‘Who knows?’ ”

“There isn’t a level considered ‘overdose’ for MDMA. That’s true of most substances,” said Kleiman. Most deaths that have been linked to Ecstasy are mostly due to circumstances like overexertion from continued dancing, poor ventilation and hydration, or from mixing the drug with other substances.

Still, those few widely publicized deaths have prompted users to become more cautious.

To combat the unintentional ingestion of contaminated doses, EcstasyData.org allows users to compare a tablet to more than 850 variations posted online, and find out exactly what substances it contains. In examining the most recent test results, over half of the variants sampled either didn’t even have any Ecstasy in them at all, or they featured Ecstasy mixed with varied amounts of other drugs such as caffeine, acetaminophen, codeine, amphetamines, ketamine, or dextromethorphan (an ingredient in cough syrup).

Yet there is still little common knowledge of the fact that the most seemingly benign, or even beneficial, of ingredients—water—can be a killer.

After severe cases of dehydration showed up in relation to Ecstasy use at raves, drinking large amounts of water became a well-known way among users to ward off the combined effects of Ecstasy and hours of dancing.

“The word got out to drink lots of water,” Kleiman said, “and now some people are dying from that.”

If the user hasn’t been dancing, drinking too much water can be detrimental, sometimes even deadly, according to Dr. Christina Haller, a toxicologist with the University of California at San Francisco.

What happens is that Ecstasy causes the release of vasopressin, in addition to the serotonin dump that causes all those happy feelings that the drug is named for. Vasopressin in the system can cause SIADH, a situation where the kidneys secrete an anti-diuretic hormone.

This means you quit processing water the normal way: urination. If you’re not peeing, you have to get rid of your water other ways—such as vomiting and profuse sweating—or it will overwhelm your systems, essentially drowning you from the inside. Electrolyte imbalances can cause even worse problems at this stage, a situation called hyponatremia that can quickly lead to death, Haller explained.

That’s what happened to Anna Wood (age 15, Australia, 1995), Brittney Chambers (age 16, Colorado, 2001) and Leah Betts (age 18, U.K., 1995). Maybe that’s what happened to Nicole Crowder, too.

“The only way to determine SIADH is to test the sodium levels in the bloodstream,” said Haller. But the sodium serum levels weren’t tested in the Crowder case, according to Sutter County Sheriff Capt. Dearl Skinner.

Haller, who reviewed the autopsy with her toxicology colleagues at UCSF, said they had no way to tell from the tests performed so far exactly how Crowder died. “Many complications may have arisen while she was left alone, such as seizures, cardiac arrhythmias, hyperthermia.”

Also raising the possibility that Crowder may have ingested too much water once her trip went bad is the fact that, in his autopsy report, medical examiner Dr. Brian L. Peterson said most internal organs appeared normal, except the lungs, which contained an unusually large amount of fluid.

These hyponatremia deaths, although rare, have caused the modification of harm reduction measures to recommend that users drink one pint of water or sports drink per hour if dancing, and even less if you aren’t active.

Why didn’t the teens call an ambulance when Crowder grew ill? According to Lt. Oller, that wasn’t something the partygoers seriously considered that night. “Imagine teens at a weekend party. Vomiting just isn’t an emergency,” he said.

But perhaps other factors were at play. According to early reports, police officials were investigating whether guests were afraid of calling for help for fear that they would get into trouble. Criminal charges still might be filed against those who did not seek medical help for Crowder, although the final police report has not been sent yet to the Sutter County District Attorney’s Office.

In the current climate of the war on drugs, the teens had reason to fear punishment. In February, two Yuba County residents were sentenced to three years in prison for manslaughter, where they gave a syringe of heroin to a woman who later died. Oller confirmed that manslaughter might be among the charges that could be brought in this case, in addition to drug possession, sales and a death involving a felony.

For some reason, teens are willing to bet that they’ll avoid the short- and long-term damage that Ecstasy can cause. “I think the lack of government-funded scientific research about whether there are safer ways to consume this drug means that we’re forcing the millions of people who take it to gamble with their health,” said Kleiman.

Nicole Crowder and her contemporaries appeared willing to tackle those odds. Until those motivations become clearer, and the education efforts become less focused on infrequent consequences, all the XTC commercials across the nation won’t have much of an effect.

Capt. Skinner didn’t seem very optimistic, either. “I think Ecstasy is the thing of the future,” he said. “This was the first death we’ve seen around here. But it won’t be the last.”