CMAJ OPEN

Paramethoxymethamphetamine (PMMA) is a ring-substituted amphetamine, similar in structure to 3,4-methylenedioxymethamphetamine (MDMA or “ecstasy”) but substantially more toxic (Figure 1).1 With nearly 50 documented deaths in Europe, Asia, Australia and Israel, PMMA has earned the street names “Death ” and “Dr. Death.”2 Although the drug has been found in a small fraction of ecstasy pills confiscated during drug seizures, it is responsible for a disproportionate number of deaths.3 Clin ical features include hyperthermia, serotonin syndrome and multiorgan dysfunction.2,4–8 Prior information on PMMA exposures has been limited to case reports or case series that focused on either the clinical or the postmortem features. Furthermore, descriptions of strate-gies adopted in response to outbreaks of PMMA-associated deaths are limited. Over an 11-month period from June 2011 to April 2012, there were 27 confirmed deaths from exposure to ecstasy containing PMMA in the provinces of Alberta and British Columbia, Canada. We describe the clin ical features observed with fatal PMMA exposures in Alberta and BC. We also describe the public health interventions that were imple-mented in response to the deaths, to provide an overview of the different services and organizations involved. Deaths from exposure to paramethoxymethamphetamine i