When the party truly ends
Sure, MDMA (Molly, ecstasy) is very safe. But not completely safe. Some people have paid the ultimate price for their search for a good time.
(Be sure to also read Water Intoxication.)
This section is a more for historical/human interest than medical information; it tells the stories of some unlucky (and in some cases, lucky) people who ran afoul of trouble in the pursuit of a high. The cases chosen for inclusion are simply ones I found interesting, with no particular effort made to cover the range of adverse events documented.
Case 1: Accidental overdose.
Victim: 24 year old white male drug dealer, approximately 77 kg. (1979.) 
7:30 p.m. Victim was at a party, where he was witnessed to take a 300 mg tablet of methaqualone (a sedative.)
7:45 p.m. The man ‘parachuted’ (swallowed wrapped in tissue paper) approximately half a gram (500 mg) of what he believed to be a mixture of LSD, amphetamine, and morphine.
11:00 p.m. He took an additional 700 mg of the powder. An hour later, he was heard to complain that he ‘needed rest’ and laid down.
1:00-2:00 a.m. He begins to thrash about violently and is incoherent. In spite of apparently having to be resuscitated by CPR, no medical assistance is summoned. Eventually the subject appears to be improving, and falls asleep.
2:30 a.m. He is found completely unresponsive. An ambulance is summoned, but the victim appears to have been dead on arrival at the hospital.
Toxicology determined that the ‘drug mix’ the victim had consumed well over a gram of was in fact pure MDA powder. (MDA is a somewhat more potent cousin of MDMA.) Toxicology reported a blood MDA concentration of 10 ng/ml, about twenty times what would be expected from a moderate recreational dose.
This appears to be the first known death from an MDxA compound.
There are perhaps two lessons here. First, if a dealer could be that wrong about their own product, are you sure your dealer knows what he has and how to use it safely? Secondly, never hesitate to call an ambulance or go to a hospital if somebody is having problems.
Case 2: Accidental death through impaired judgement.
Victim: 22 year old male ecstasy user (1987.) 
A body is found at the base of a large metal electrical tower. The medical examiner reconstructs events based on his examination of the body, concluding that the victim had climbed the tower to a height of about 40 feet, where he came into close contact with one of the 138,000-volt high-power lines. It was unclear if the shock or the fall killed him. Toxicology reports an unknown quantity of MDMA in his blood; no other drugs or alcohol.
Beyond the strange particulars of this death, it is extraordinary for having happened at all; MDMA tends to produce a paranoia of physical dangers. Death by misadventure is rare, especially in the absence of other drugs (like alcohol.) Unfortunately it couldn’t be determined if the victim was high when he attempted the climb, but it seems likely that he was; the immediate aftereffects of MDMA usually involve lethargy/fatigue and a general avoidance of stimuli.
Case 3: Asthma.
Victim: 32 year old male (1987.) 
Victim was found dead in his car, with his 0.5% epinephrine rescue inhaler in his hand. The death was ruled to be due to severe asthma, but toxicology reported a blood MDMA concentration of 1.1 ng/ml, about twice the level a moderate recreational dose would be expected to produce.
This seems to be the only documented case of death involving MDMA and asthma. Although causality is unclear, it wouldn’t be surprising if the high dose of MDMA consumed was an aggravating factor.
Case 4: Psychosis and attempted suicide after extremely heavy abuse of ‘ecstasy’.
Patient: 22-year-old male. 
The patient was brought into the Emergency Department, having been injured after repeatedly leaping into the path of oncoming traffic. Questioning by a psychiatrist eventually revealed that the young man had been using ‘ecstasy’ at a rate of 4-7 times a week for the past four months. During the week before the incident, he had become increasingly convinced that a group he had been in a fight with was trying to kill him, and had apparently decided to deny them the pleasure by doing the job himself. The patient was treated and released, but came back to the hospital two months later, reporting that although he had ceased using ‘ecstasy’, he continued to have ‘flashbacks’ (feeling as though he were high on MDMA) and once again believed he was being persecuted, etc.
Treatment with medication produced full remission, and medication was withdrawn after four months. Eight months after the initial incident, he began to use ‘ecstasy’ again and suffered another psychotic break, which he recovered from in about a week.
This is an interesting case of psychosis developing in the wake of severe amphetamine abuse. His period of abuse may have sensitized him to further relapses from even moderate use of MDMA. It has been suggested by some that MDMA cannot produce psychosis, and under typical patterns of use I would be inclined to agree. However, with heavy abuse, the effect of the drug appears to become more amphetamine-like as the less robust serotonergic system contributes less and less of an effect to the total ‘high’ and dosages increase.
Case 5: Death through missadventure while intoxicated on multiple substances.
Victim: 26-year-old male (1994). 
A young man died 36 hours after being brought in to the Emergency Department with a severe head injury. Toxicology reports 0.63 ng/ml of MDMA (consistant with being quite high at the time) and a blood alcohol level of 0.123% (decidedly drunk.) The pathology of injuries was unremarkable, but how he got them was: At the time his injuries were sustained, he was “car surfing”; standing on top of a car’s roof while holding onto ropes coming out of the front side windows. During acceleration in a straight section of road, he lost his balance and fell. Interviews with the guests at the party he had been at reported that this act had been the culmination of a series of dares and stunts between a number of young men performing for a cheering audience of young women at the party.
MDMA makes you impaired but largely aware of it. Alcohol makes you impaired and largely unaware of it. Combining the two in generous amounts can produce a severe level of intoxication with minimal self-awareness of that fact.
Case 6: Fatal accident caused by drugged driving.
Victim: 29-year-old white male (1996.) 
While driving by himself down a highway, the man’s car veered off the road, rolling down an embankment and ejecting the driver. The responding ambulance declared him dead when they arrived. Toxicology screening revealed a blood MDMA concentration of over 2 ng/ml, about 4 times the peak level produced by a moderate (1.5 mg/kg) dose. It’s no wonder he couldn’t drive, although it’s likely the crash would have been survivable if he had been wearing a seatbelt.
Case 7: Liver damage from accidental poisoning (not MDMA related.)
Patients: Five males, one female, ages 17-25 (1997.) 
In the days after a party, young people began trickling into a local hospital with severe abdominal pain and signs of liver damage. Interviews revealed that they had all consumed a beverage laced with “MDA” at the party (the “MDA” had been supplied by one of them.) Upon further questioning, it was learned that the individual who supplied the “MDA” had discovered that a local chemical company was selling it and, delighted to find what he believed was an illegal recreational drug being sold openly and over-the-counter, had purchased some. Unfortunately for his friends, he decided to share his new ‘stash’, offering some to them as well as taking some of the spiked punch himself. (They were apparently all aware of this; nobody was ‘drugged’ unwittingly.)
Upon further investigation, it was discovered that the fortuitous find of a local “MDA” source was not so fortunate or surprising: The chemical in question was Methylene Di-Analine, a chemical used in the manufacture of polyurethane foam…not the desired drug MethyleneDioxyAmphetamine. All made a full but painful recovery and were presumably wiser for the experience.
Case 8: Self-inflicted lung injury.
Patient: 17-year-old girl (1997.) 
The patient presented at the hospital complaining of chest pain several days after using ‘ecstasy’ at a party. X-rays revealed a pneumomediastinum; a bubble of air settled in the lining around her heart. She made a swift recovery with minimal treatment.
Interviews with the girl revealed that she had danced almost continuously for about eight hours while blowing on a whistle. This repeated overpressurization of the lungs had caused sufficient damage to the fine blood vessels in them to allow air to be forced into the bloodstream, where it collected near the heart (and also in a neck artery.)
This sort of injury is also sometimes seen in people who smoke drugs due to forcibly holding in the smoke.
My sympathy for the patient is greatly blunted by the sort of nuisance she apparently made of herself at the party with that whistle. Nobody likes an e-tard with a whistle or siren.
Case 9: Attempted suicide.
Patient: 30-year-old male (1998.) 
A young man is brought into the hospital after being found unconscious and convulsing, with a rapid pulse and elevated body temperature. Aggressive ‘stomach pumping’ recovered 2.8 grams of MDMA from his stomach. With treatment of the symptoms, the patient made a full recovery over the next two days, and was released on the third day. Upon recovery, he told doctors that he had taken a total of 50 tablets of ‘ecstasy’, 100 mg of oxazepam (a benzodiazepine sedative), and five alcoholic beverages in a suicide attempt.
His survival is primarily due to prompt treatment, but ironically, his drug mixing may also have helped save him, with the alcohol and oxazepam partially counteracting the MDMA’s stimulant effects. He was also in a cool, quiet environment which presumably further reduced the severity of hyperthermic response.
Case 10: Overdose (accidental?)
Patient: 19-year-old-male, weight 75 kg (1999.) 
Subject was found confused at home approximately 12 hours after taking as many as 40 tablets of ‘ecstasy.’ At the hospital, the patient was sluggish but responsive and cooperative, showing normal blood pressure, normal body temp, and moderately elevated pulse. He remembered nothing of the day leading up to his admittance to the hospital. Blood alcohol of 0.13%. At 13 hours after taking the pills, his blood serum level of MDMA was still 4.3 ng/ml, about 8-10 times the peak a moderate recreational dose would produce.
The patient was treated and rapidly improved; 24-hours after being brought in, he checked himself out against doctor’s advice. When he left the hospital, his blood MDMA level was still 0.75 ng/ml (comparable to what a high recreational dose might produce at its peak aprox. 2 hours after ingesting it.)
This case may not have been a suicide attempt; simple bad judgment may have been to blame. As before, it’s possible that the alcohol reduced the danger of fatal heatstroke, but it would be extraordinarily unwise to regard alcohol as a treatment for MDMA overdose.
Death by MDMA overdose strikes me as a horrible way to go; just because it’s a pleasant high at normal doses doesn’t mean it’s fun as an overdose.
Case 11: Arrestee suicide?
Victim: 53-year-old male Doctor of Psychiatry (1999.) 
The victim was found in distress in a jail cell eight hours after his arrest for possession of “marijuana and narcotics.” A hand-written will was found with him. In spite of aggressive emergency treatment, the victim suffered heatstroke-induced multiple organ failure (reaching a peak temperature of over 107F.) He died in the hospital five days later, having never regained consciousness. Toxicology revealed a massive MDMA overdose; at the autopsy, he still had potentially lethal levels of MDMA in his system.
The case report doesn’t go into the legal details of the case, but given the timing, the likely scenario is that the victim had a large quantity of MDMA in his posession. When he realized he was about to be arrested, likely ending in prison time, the loss of his medical license, and public humiliation, the doctor apparently decided that the only real option left was to swallow the stash. It’s not entirely clear that this was a deliberate suicide. He may have had hopes of surviving the extreme overdose, but as a doctor, he must have known that his decision was likely to be fatal.
Why he had the drugs on him is unknown, but given his medical credentials, it’s quite possible that he was involved in the theraputic use of MDMA in his practice (something that continues to this day in spite of the government ban.) Poklis A, Mackell MA, Drake WK “Fatal intoxication from 3,4-methylenedioxyamphetamine” Journal of Forensic Science, 1979; 24(1):70-5. Abstract.  Dowling GP, McDonough ET 3rd, Bost RO “‘Eve’ and ‘Ecstasy’. A report of five deaths associated with the use of MDEA and MDMA” JAMA, 1987; 257(12):1615-7. Abstract.  Creighton FJ, Black DL, Hyde CE “‘Ecstasy’ psychosis and flashbacks” Br J Psychiatry, 1991; 159:713-5. Abstract.  Hooft PJ, van de Voorde HP “Reckless behaviour related to the use of 3,4-methylenedioxymethamphetamine (ecstasy): apropos of a fatal accident during car-surfing” Int J Legal Med, 1994; 106(6):328-9. Abstract.  Crifasi J, Long C “Traffic fatality related to the use of methylenedioxymethamphetamine” J Forensic Sci, 1996; 41(6):1082-4. Abstract.  Tillmann HL, van Pelt FN, Martz W, Luecke T, Welp H, Dorries F, Veuskens A, Fischer M, Manns MP “Accidental intoxication with methylene dianiline p,p’-diaminodiphenylmethane: acute liver damage after presumed ecstasy consumption” J Toxicol Clin Toxicol, 1997; 35(1):35-40. Abstract.  Ramcharan S, Meenhorst PL, Otten JM, Koks CH, de Boer D, Maes RA, Beijnen JH “Survival after massive ecstasy overdose” J Toxicol Clin Toxicol, 1998; 36(7):727-31. Abstract.  Regenthal R, Kruger M, Rudolph K, Trauer H, Preiss R “Survival after massive ‘ecstasy’ (MDMA) ingestion” Intensive Care Med, 1999; 25(6):640-1. Abstract.  Walubo A, Seger D “Fatal multi-organ failure after suicidal overdose with MDMA, ‘ecstasy’: case report and review of the literature” Hum Exp Toxicol , 1999; 18(2):119-25. Abstract.  Pittman JA, Pounsford JC “Spontaneous pneumomediastinum and Ecstasy abuse” J Accid Emerg Med, 1997; 14(5):335-6. Abstract.