Between 2011 and 2017, MDMA-related death rates increased in Australia, Finland, Portugal, and Turkey, coinciding with higher MDMA purity and availability. Across 1,400 deaths in Turkey, 507 in Australia, 100 in Finland, and 45 in Portugal, most decedents were young males (81–94% male; median age 24–27.5 years). Drug toxicity was the primary cause in Australia (61%), Finland (70%), and Turkey (60%), while other causes dominated in Portugal (56%). Only 13–25% of deaths were due to MDMA alone; these had significantly higher blood MDMA concentrations than multiple-drug toxicity deaths. Other drugs commonly detected included stimulants and alcohol in Australia and Finland, benzodiazepines and opioids in Finland, and synthetic cannabinoids and cannabis in Turkey.
Amphetamine, methamphetamine, and MDMA have a similar capacity to cause death when fatal toxicity is expressed as deaths per million doses. In Finland, poisoning deaths from these stimulants correlated significantly with drug consumption measured by wastewater-based epidemiology across the years 2012, 2014, 2016, 2018, and 2020. Methamphetamine showed the highest fatal toxicity (at an estimated 50 mg dose), followed by MDMA (100 mg dose) and amphetamine (50 mg dose). The fatal toxicity of these stimulants was close to that previously reported for many prescription opioids and tricyclic antidepressants. This is the first study to quantitatively compare fatal toxicity of amphetamine-type stimulants by linking deaths with consumption estimates from wastewater.