How risky is ecstasy? A model for comparing the mortality risks of ecstasy use, dance parties and related activities.
Russell Newcombe & Sally Woods
Centre for Applied Psychology, School of Human Sciences, Liverpool John Moores University, Henry Cotton Campus, Webster St., Liverpool, L3 2ET, England
3D Research Bureau, 47 Arundel Avenue, Liverpool, L17 3BY, UK Tel: +44 (0)151 280 9690
Ecstasy-related deaths received constant attention from the mass media in the 1990s, far more than deaths involving other drugs or risky sports (Newcombe 1997). But our current scientific knowledge of the mortality risks associated with dance drugs/parties and comparable activities is limited. This paper assesses evidence on the aetiology of deaths in the UK since 1980. A nine-level model of annual mortality risk (AMR) is presented, in order to facilitate comparisons between the risks presented by different types of drug use, leisure activity, disease, accidents, and other exposures (e.g. occupation). The highest two levels of risk – maximum risk (AMR of up to one in one) and extremely high risk (midpoint AMR of one in ten) are largely theoretical categories (Levels 0 and 1), except for the risks posed by some surgical operations. Level 2 – very high risk – corresponds to a midpoint AMR of one in 100, and includes tobacco smoking, methadone use, and drug injecting; with comparable risks presented only by such dangerous sports as mountain climbing, common fatal diseases such as cancer, and working in space or at sea. The lowest level of risk - Level 8, minimum risk (AMR over one in 50 million) – includes use of caffeine, DMT and laughing gas; along with table games, smallpox, snakebites, and meteorites. Ecstasy use and dance parties are classified within the model as quite low risk (Level 5 - midpoint AMR of one in 100,000) – along with, for instance, use of cocaine, speed, and analgesics; and, snow sports, DIY, food poisoning, air travel, passive smoking and homicide. Use of hallucinogens is very low risk (Level 6 - AMR of one in a million) – along with antibiotics, fairground rides, food allergies, police cars and vaccinations. It is concluded that the mortality risks of ecstasy use and dance parties are relatively low in comparison to many other types of drug use and leisure activity, both legal and illegal – as well as in comparison to the risks presented by particular occupations and diseases. Research is needed to develop the theoretical scope and empirical basis of risk assessment models, including mortality exposure risks (prevalence x frequency x level), and morbidity and injury risks.
1. Trends in deaths from ecstasy and speed in the UK
Ecstasy-related deaths received disproportionate attention from the mass media in the 1990s, particularly compared with fatalities from other popular dance drugs, such as speed and cocaine, and compared with other leisure activities, such as climbing sports (Newcombe 1997). This paper asks how lethal ecstasy really is, and assesses two key sources of relevant evidence: official statistics on drug-related deaths in Britain, from 1980 to 1995, and reports on drug-related deaths in the British press, between 1988 and 1997. To simplify interpretation in the present analysis, we focus on a comparison of deaths involving ecstasy (illicit tablets and capsules containing MDMA and/or related drugs) and deaths involving speed (illicit amphetamine sulphate, usually in powder form). It should be noted that categorisation and counting of relevant cases is based on various assumptions, and thus any conclusions drawn should be cautious and tentative. For instance, many or most of the deaths represented by these statistics involved poly-drug use, (e.g. ecstasy and speed; ecstasy, cannabis and alcohol) and each case which involved ecstasy – alone or with other drugs - is counted as an ‘ecstasy death’.
There are two additive sources of official statistics on drug-related mortality: verdicts of dependent or non-dependent drug abuse by Coroners Courts, and reports by doctors on death certificates of fatal poisoning by controlled drugs.
First, between 1986 and 1995 there were 58 Coroners’ verdicts of deaths by drug abuse which implicated amphetamine-type drugs (notably ecstasy and/or speed). Cases of fatal poisoning during the same decade indicate a further 100 deaths involving speed and 45 involving ecstasy (MDA-type drugs, typically MDMA). Separate figures for ecstasy and speed deaths have been made available on both official mortality indicators since 1993. Between 1993 and 1995, the total number of ecstasy-related deaths was 55, while the total number of speed-related deaths was 73. Speed deaths peaked in 1995 (34), while ecstasy deaths peaked in 1994 (29). Employing British Crime Survey prevalence statistics, the annual mortality rate for ecstasy users in 1994 was estimated to be 40 linked deaths per million users, compared with 12 speed-linked deaths per million speed users (and one LSD-linked death per million LSD users).
Second, a review of newspaper reports revealed 114 deaths linked to dance drugs/parties in the decade January 1988 to December 1997 – of which 78% involved ecstasy, and 7% involved speed. The typical case was a man in his early 20s, who had taken two or three tablets at a dance party or nightclub, often with other drugs such as speed, cannabis or alcohol, and who was later admitted to hospital showing signs of heat exhaustion or heatstroke. Estimated mortality rates based on press reports declined steadily from 31 linked deaths per millionecstasy users in 1992, to 21 in 1994 and 12 in 1996. Trends generally mirrored those indicated by official statistics, though the annual number of reported speed deaths was significantly lower than the official toll. It is concluded that the British press – particularly tabloid but also broadsheet newspapers - are guilty of sensationalism, providing coverage of the majority ofecstasy deaths (typically with graphic headlines and moralistic editorials) while reporting only a minority of the fatalities linked to equally prevalent and risky drugs such as speed and cocaine.
2. A model for comparing deaths from ecstasy use and other activities
Clearly, health educators and promoters need to find ways of providing potential and present drug users with more accurate information about the risks of drugs - or, as Calman (1996) put it in a more general context: "how best to communicate the level of risk associated with a particular health issue to the public". Since death is undeniably the top risk of all health risks, it is an appropriate starting place to construct a tentative model for comparing the relative risks of different types of drug use or leisure activity. Unfortunately, as noted above, evidence about the mortality risks associated with dance drugs/parties and comparable activities in the UK is limited, and permits the construction of only a basic model employing unadjusted numerators and denominators. That is, in the case of the numerator, the available evidence from official figures and other sources permits calculations of the standard figure for annual mortality rates only – namely, the number of individual deaths linked to each risk factor. Two other more accurate procedures for producing numerators are not employed. First, there is insufficient evidence about the age of people involved in many categories of death to provide comprehensive estimates of the number of lost life-years (average life expectancy minus average age of death) across a broad range of relevant risk factors. The adjustment for lost life-years is particularly relevant when comparing mortality rates for users of drugs such as tobacco - who typically die from diseases related to their habit about 10 years earlier than non-users (e.g. in their mid-60s compared with mid-70s) – and for users of drugs such as heroin, who typically die four or five decades earlier than non-users (i.e. in their 20s and 30s).
Second, adjustments for how many people would have died if a particular risk factor had not been present – for instance, if a person took one course of action rather than several possible alternatives - are also prevented by lack of relevant data and conceptual modelling. For instance, up to one in three patients in intensive care treatment dies, though all or nearly all of them would be likely to die without such medical intervention. More complex issues are raised by considerations such as this: if a person decides to travel by air and face the attendant risks, then they are not travelling by other methods - e.g. rail, road - and have reduced the risks associated with these factors - including staying at home! In the case of the denominator, relevant information from diverse sources generally provides estimates of the number of people involved in various activities (e.g. how many people travelled by plane last year, how many used ecstasy) – but does not provide the same detailed kind of information about people’s frequency of involvement (e.g. number of flights taken, number of occasions on which ecstasy was taken) or their quantitative level of exposure (e.g. total flying hours, total amount of ecstasy consumed). In short, the available evidence on the aetiology of deaths in the UK over the last decade can be used to build a preliminary comparative model of mortality risks related to drug use, leisure activities and other life events. Though the limitations of such a model should now be clear, it should at least provide a more reliable foundation for informing the public about the risks of drugs than current reports on drug-related problems in the press.
A nine-level model of annual mortality risk (AMR) is suggested, in order to facilitate comparisons between the scale of the mortality risks presented by five categories of causal factor: drug use, leisure activities, disease and illness, general accidents and injuries, and a special group of accidents and injuries based on factors in the organisational world (work, business) and the physical world (environment, including weather). Several sources of information were employed to provide figures for the numerator and denominators in the mortality rates. Regarding numerators, statistics on the annual number of drug-related deaths to 1995 were derived from tables provided in the Statistics of Drug Addicts Notified to the Home Office 1996 (Home Office 1997), while statistics on drug-related deaths for 1996 to 1998 were obtained from Hansard. Figures for deaths related to other factors – including leisure activities, diseases, and accidents – were obtained from a variety of sources, notably annual bulletins on Mortality Statistics and Coroners’ Inquests. Regarding denominators, estimates for the prevalence of drug use in Britain are based on the British Crime Survey (Ramsay & Partridge 1999), while figures for population numbers relating to other activities and events were obtained from a variety of sources, often via the Internet. These included organisations representing different sports and travel modalities, and Census figures on the number of people in different occupations, age-groups, etc. Statistics based on risk factors to which the whole population can be assumed to be potentially exposed – for instance influenza and insects - employ the figure for the British population as a denominator (about 55 million).
The nine categories, each with its own label indicating the level of high or low risk, are numbered zero to eight. These Safety Degree Units (Urquhart & Heilmann 1984) indicate the logarithmic value of the annual mortality rate (AMR) represented by each category (see Calman 1996, for an earlier model of general mortality risks). Thus, Level 0 represents the AMR of 1 in 1 and covers the range of AMRs up to 1 in 5; Level 1 represents AMRs which approximate the standard rate of 1 in 10, and thus covers the range of AMRs between 1 in 6 and 1 in 50; Level 2 represents AMRs which cluster around the standard rate of 1 in 100, and thus incorporates the range of AMRs between 1 in 51 and 1 in 500; and so on. The highest two levels of risk – maximum risk (AMR of up to 1 in 1) and extremely high risk (AMR of around 1 in 10) - are largely theoretical categories. This is because risk factors in Level 0 are associated with fatalities amongst 20% or more of the people exposed to them in a year, while risk factors in Level 1 cause the deaths of between 2% and 19% of the people exposed to them in a year – far higher levels of mortality risk than are presented by the activities and situations faced by the vast majority of people in everyday life. However, being a patient in intensive care falls into Level 0, while undergoing brain surgery falls into Level 2 (along with Russian Roulette!).
Thus, useful comparisons within the model typically start at around Level 2 – very high risk – which corresponds to an AMR of around one in 100, and includes tobacco smoking, methadone use, and drug injecting; with comparable risks presented only (a) to small groups of people involved in the highest-risk sports (notably mountain climbing) and environments (space, deep sea); (b) to patients in surgical operations; or (c) by the general risk of death (usually in old age) from one of the three big diseases: cancer, heart disease, or respiratory disease. Level 3 –quite high risk – represents AMRs which cluster around the standard rate of one in 1,000, including the use of alcohol, heroin, and morphine; along with the specific mortality risks presented by involvements with hang gliding, motorbike racing, working in mines and oil rigs, mental disorder, and the general risks of death by violence or pollution. Level 4 – medium risk – pivots on an AMR of around one in 10,000. It includes the use of solvents, tranquillisers and weaker opiates, along with participation in water sports and motor sports, and farming and construction work; and the general risks presented by diseases such as diabetes and influenza, and other factors such as road travel, giving birth, suicide, being in police custody, and receiving a general anaesthetic from a dentist.
At the other extreme, the lowest level of risk - Level 8, minimum risk (AMR of over one in 50 million – effectively zero) – includes use of caffeine, DMT and laughing gas; along with table games, smallpox, and snakebites. Above the bottom level is Level 7 - extremely low risk (AMR of around one in 10 million) – which includes rare deaths from cannabis and poppers amongst users of these drugs; along with playground accidents amongst children, CJD amongst meat-eaters, and insect stings and lightening strikes in the general population. The use of hallucinogens such as LSD is classified as very low risk (Level 6 - AMR of around one in a million) – along with antibiotics, fairground rides, food allergies, war and vaccinations. Both ecstasy use and dance parties are classified within the model as quite low risk (Level 5 - AMR of around one in 100,000) – along with use of cocaine, amphetamines, and analgesics; and, participation in snow sports, field sports and DIY; along with more general risks presented by food poisoning, HIV, passive smoking, being X-rayed and homicide. It is concluded that the annual mortality risks of ecstasy use and dance parties are relatively low in comparison to many other types of drug use and leisure activity – with higher risks also being presented by other routine activities (work, travel, domestic tasks, etc.) or occasional exposures (to diseases, medical treatments, weather conditions, etc.).
3. Conclusion: risk assessment models require greater development
Research is urgently needed to develop theory and research into drug-related risk assessment models, including more sophisticated analyses based on numerators and denominators that more accurately represent people’s total exposure to drug use and other potentially fatal activities and events. Clearly, improvements are needed in both our methods of categorising and counting the causes of death, and also to our methods of estimating the prevalence of various activities and events associated with mortality. Research is also needed to produce denominators which more accurately represent the causal influence of various mortality factors, including the frequency of an activity/event (e.g. number of days on which ecstasy was used, number of days on which mountains were climbed) and the amount of exposure (e.g. dose ofecstasy consumed on each day of use, distance climbed).
Similarly, mortality risk assessment models must also be developed to take account of lost life years (i.e. average age of deaths related to various causes), and the effects on overall mortality risk of engaging in particular activities/events (eg. road travel) rather than others (eg. rail travel). Finally, risk assessment models are also needed to organise and interpret evidence about the non-fatal consequences of drug use and other activities, such as physical illness and injury, mental disorders, and social problems.
When the knowledge bases and statistical techniques for providing such risk assessment models have been more fully developed, we will then be in a position to provide the public with educational products and services which allow them to make fairer assessments of ‘risk’ in everyday life. The chart presented here, with user-friendly terminology and minimum use of statistics, hopefully provides a useful starting-point for this task.
SDU = Safety Degree Unit (logarithmic)
AMR = annual mortality rate
DRD = drug-related death
Numerical risk = numerator-denominator ratio expressed as one death per X people exposed to risk over one year (where X represents a pivotal point in a standard numerical range):
1 in 1 = 1 in 1 to 1 in 5 (or: between 20% and 100%)
1 in 10 = 1 in 6 to 1 in 50 (between 2% and 19%)
1 in 100 = 1 in 51 to 1 in 500 (from 0.2% to 1.9%)
1 in 1,000 = 1 in 501 to 1 in 5,000 (0.02% to 0.19%)
1 in 10,000 = 1 in 5,001 to 1 in 50,000
1 in 100,000 = 1 in 50,001 to 1 in 500,000
1 in 1,000,000 = 1 in 500,001 to 1 in 5,000,000
1 in 10,000,000 = 1 in 5,000,001 to 1 in 50,000,000
1 in 100,000,000 = over 1 in 50,000,000
The annual number of deaths associated with particular drugs/causes (the numerator) is based on the yearly average for the 1990s in the UK, or else the most recent annual figures in the 1990s (non-fatal illnesses and injuries are not included). Denominators are based on the most recent prevalence figures for each type of drug use (eg. British Crime Survey) or other risky activity in the UK resident population. Activities involving the entire UK population are based on a denominator of 55 million; the adult population: 40 million; etc.. This relatively simple model is based on annual prevalence only – i.e. numbers exposed to the cause during the past year – and thus does not take account of: (1) Frequency of occasions/exposures - eg. attendance at dance parties; frequency of flying, playing sport, etc.; (2) Magnitude of cause – eg. dose of drug; duration of dance party; total flying/playing hours, etc. In addition, the model does not take into account life-years lost by particular types of death (eg. fatal heroin ODs cost more in life-years than smoking-related deaths – because age at death is typically 20-40 rather than 60-80).
Drug use: Hal. = hallucinogenic dextropropoxy. = dextropropoxyphene (eg. Distalgesic) Contracep..pill = contraceptive pill (about 10-20 deaths annually among 3 million women)
Analgesics – includes aspirin, paracetamol, codeine and ibuprofen (i.e. OTC pharmacy pills/potions for headaches and pain relief) # Presc. drugs = adverse reactions to prescription drugs
Note: many DRDs involved poly-drug use, and were counted once under each drug; and many deaths also involve multiple activities (eg. drink-driving; ecstasy & speed use while dancing; etc.)
Leisure activities:* Russian roulette: included as a theoretical (and humorous) example - the prevalence and outcomes of Russian roulette playing are not known
~ Mountain sports: estimated 200,000 mountain climbers in UK – and 116 deaths in a decade; (a) Serious climbing (dedicated experts) - AMR of 1 in 167;
(b) recreat(ional) climbing - AMR of one in 1,750; (c) mountain hiking – AMR of one in 15,700 [BASE jumping: parachuting from Building, Antenna, Span & Earth ]
*** Water sports: involving equipment - ( i.e. not simple swimming/diving sports) - eg. boating, surfing, water skiing, scuba-diving, & canoeing (1 in 13,200)
Air sports: flying, hang-gliding, parachuting etc. Mountain sports: rock climbing, ice climbing, walking, etc.
Motor (vehicle) sports: car/motorbike racing etc. Riding (animal) sports: mainly horse racing and dressage Snow (winter) sports: skiing, skating, tobogganing, snowmobiling etc.
Fighting sports: boxing, wrestling, kick-boxing, judo, karate, martial arts, etc. < Field games: involving equipment/balls, other than soccer/rugby, eg. hockey, cricket, baseball, tennis, etc.
Indoor sports: badminton, table tennis, basketball, volleyball, bowling, darts etc. Table games: card games, board games, word games etc.
Diseases/illnesses - based on number of people whose behaviour exposes them to the disease (eg. all for heart disease; meat-eaters for CJD; sexually active for AIDS)
Heart disease – 300,000 deaths caused by cardiac and circulatory diseases, including strokes Respiratory diseases – 100,000 deaths per year (bronchitis, emphysema, etc.)
Cancer – mainly of the lungs, colon/rectum, and breast Hypothermia etc. – i.e. an annual count of 30,000 deaths due to excessive cold (mainly hypothermia among the elderly)
Accidents/injuries – based on number of people exposed to risk of accident or injury in everyday life – focusing on the home, transport systems, and public places
Road travel (about 4,000 deaths a year): including vehicle drivers & passengers (2,000), motorcyclists (700), and cyclists (200); air travel causes about 100 deaths, water travel about 50.
Rail travel etc.- includes train crashes (48 deaths in 1998), trespassers on tracks (265), level crossing collisions (14), and falling off trains (15).
Snakebites, shark attacks, earthquakes and state executions were used as examples because there are typically zero deaths in such categories in the UK, though figures are much higher in other
parts of the world (eg. 40,000 people die from snakebites worldwide annually); while deaths from (e.g.) meteorites and spontaneous combustion (sp. comb.) are zero throughout the world
! carbon monoxide poisoning from boilers, heaters or stoves which burn gas, coal, oil or wood C.A. Child abuse
Copulation – deaths from exertion during copulation and/or fetish-related fatal accidents, eg. auto-erotic asphyxiation
Other exposures – generally covering exposures to three particular types of risk: medical/ police interventions; occupational risks; and weather and environmental conditions
** Other surgical operations with a 1 in 10 risk of death include surgery for oesophagectomies. Also, half of all patients waiting for a lung transplant die while waiting for a suitable organ.
Caesarean birth – maternal death rate (1 in 3000 – compared to overall maternal AMR of 1 in 10,000) Intensive care: one in every 3 to 5 patients dies liposuct.: liposuction
Refusal of int(ensive) care – estimated number of deaths caused to patients who were refused intensive care by hospitals (based on whole population); GA: general anaesthetic
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