Severe paramethoxymethamphetamine (PMMA) and paramethoxyamphetamine (PMA) outbreak in Israel.

Paramethoxymethamphetamine (PMMA) is a hallucinogenic synthetic substituted amphetamine that was not included in the Israeli Controlled Substance Act (CSA). To report a severe PMMA and paramethoxyamphetamine (PMA) outbreak. The Israeli national forensic toxicology laboratory analyzes the body fluids of unnatural deaths by means of screening immunoassays and chromatographic confirmation and quantification. Samples are referred to this laboratory by the Israeli Forensic Medicine Institute and by hospitals following consultation with the Israel Poison Information Center. The forensic toxicology laboratory began determining PMMA and PMA in February 2007. In all fatal cases with a positive immunoassay screen for amphetamines, a chromatographic analysis of PMA and PMMA was performed. The laboratory and demographic data of consecutive patients in whom PMMA or PMA were detected, were collected during 1 year and subjected to descriptive analysis. Of 108 fatal cases with a positive screen for amphetamines, 32 were confirmed. Twenty-four of the 32 cases tested positive for PMMA and PMA--age 27 ± 5 years, 79.2% males, post mortem whole blood PMMA and PMA concentrations 0.35 ± 0.24 and 2.72 ± 1.67 mcg/mL, respectively. Co-exposures were detected in 17 (70.8%) fatalities; including methylenedioxymethamphetamine, methylenedioxyamphetamine, cocaine, cannabinoids, cathinone derivatives, ephedrine/pseudoephedrine, opiates, and ethanol. In addition, five non-fatal male cases were identified; age 32 ± 5 years, four had co-exposures to cocaine, cathinone derivatives, and cannabinoids. These findings led to the inclusion of PMMA in the CSA in July 2007, resulting in only three more fatalities in the following year. We report an outbreak of PMMA and PMA poisoning resulting in 24 fatalities, and the post mortem whole blood and urine concentrations of these two compounds. PMA was probably the result of PMMA metabolism. Stimulant co-exposures may have contributed to the severity of the poisoning. Forensic laboratory and poison center co-operation is important in identifying a new drug of abuse.