Outdoor electronic dance-music festivals (EDMFs) are typically summer events where
attendees can dance for hours in hot temperatures. EDMFs have received increased media
attention because of their growing popularity and reports of illness among attendees
associated with recreational drug use. MDMA (3,4-methylenedioxymethamphetamine) is
one of the drugs often used at EDMFs (1). MDMA causes euphoria and mental stimulation
but also can cause serious adverse effects, including hyperthermia, seizures, hyponatremia,
rhabdomyolysis, and multiorgan failure (2,3). In this report, MDMA and other synthetic
drugs commonly used at dance festivals are referred to as “synthetic club drugs.”
On September 1, 2013, the New York City (NYC) Department of Health and Mental Hygiene
(DOHMH) received reports of two deaths of attendees at an EDMF (festival A) held August
31–September 1 in NYC. DOHMH conducted an investigation to identify and characterize
adverse events resulting in emergency department (ED) visits among festival A attendees
and to determine what drugs were associated with these adverse events. The investigation
identified 22 cases of adverse events; nine cases were severe, including two deaths.
Twenty-one (95%) of the 22 patients had used drugs or alcohol. Of 17 patients with
toxicology testing, MDMA and other compounds were identified, most frequently methylone,
in 11 patients. Public health messages and strategies regarding adverse health events
might reduce illnesses and deaths at EDMFs.
Festival A was planned to be held outdoors from 11 a.m. to 11 p.m. over the 3-day
Labor Day weekend, with approximately 40,000 attendees each day. Admission was restricted
to persons aged ≥18 years. The daily outdoor heat index was 85°F–90°F (29°C–32°C).
Alcoholic beverages were sold by concessionaires to persons aged ≥21 years. Ill patrons
could seek care onsite at medical tents, from which ambulances transported attendees
to local EDs if necessary. As a result of the two deaths, the third day of the festival
was canceled by event promoters in consultation with NYC officials.
An adverse event was defined as an ED visit among any festival A attendee ≤12 hours
after the event; a severe case was defined as one with seizure, intubation, intensive
care unit (ICU) admission, or death. Cases were identified by review of festival A’s
list of ED transports, ED registration logs for patient aged 16–30 years at nine NYC
hospitals with selected key words (i.e., intoxicated, unresponsive, seizure, altered
mental status, cardiac or respiratory arrest, or concert or festival attendee), NYC
Poison Control Center reports of intoxications, the NYC Office of the Chief Medical
Examiner list of deaths, and DOHMH’s ED syndromic surveillance system. ED records,
hospital charts, medical examiner records, and laboratory results of patients with
adverse events were reviewed. Available blood and urine samples from patients were
sent to an external laboratory for additional toxicology testing, including testing
for synthetic club drugs. Alcohol use was defined as a positive hospital laboratory
result, and drug use was defined as a positive hospital or external toxicology result.
Among cases without toxicology testing, patients were considered to have used drugs
or alcohol if such use was noted in the medical record. Positive toxicology from drugs
administered therapeutically was excluded from analysis.
Twenty-two cases were identified, 17 from the festival A ED transport list, three
from the NYC Poison Control Center database, and two from NYC ED registration logs.
Median age of the 22 patients was 21 years (range = 16–29 years). Fifteen (68%) were
residents of New York state, and four were residents of NYC. Four (18%) had body temperature
greater than 102°F (38.9°C) (Table 1).
Among the 22 patients, 21 (95%) had used drugs or alcohol. Eleven (50%) had used alcohol
with or without other drugs, and 12 (55%) had used synthetic club drugs with or without
other drugs or alcohol. Among the nine severe cases, six had used synthetic club drugs
only and none had used alcohol only. Biologic specimens were available for additional
toxicology testing from 17 patients. MDMA was identified in one decedent, and MDMA
plus methylone (a synthetic cathinone) in the other decedent. Four of 17 tested positive
for methylone alone; three for methylone and MDMA; one for methylone and methamphetamine;
one for methylone, methamphetamine, and cocaine; and two for MDMA alone (Table 2).
In comparison with other EDMFs occurring in NYC during September 2012–September 2014
or a 2010 New Year’s Eve EDMF in Los Angeles (4), the rates among attendees of hospital
admissions and ICU admission or death per 10,000 person days did not differ significantly
(Table 3). The death rate associated with festival A in 2013 also was compared with
the number of unintentional poisoning deaths from all psychoactive substances in a
comparable NYC age group during 2012, the most recent year that collated data were
available (5). Among persons aged 15–34 years, the death rate from all psychoactive
substances in NYC was 0.02/100,000 person-days, compared with 2.5/100,000 person-days
at festival A in 2013.
Discussion
This investigation identified 22 attendees with adverse events, including two deaths,
associated with an EDMF; 95% of the attendees had used drugs or alcohol, and toxicology
testing identified MDMA and other compounds, most frequently methylone. Drugs believed
to contain MDMA are sold under the street names “ecstasy” and “molly.” These illicit
substances might contain additional or substituted compounds. According to the Drug
Abuse Warning Network, the number of ED visits nationally involving MDMA increased
120% during 2004–2011 (6). Although fatal drug overdoses have been reported at EDMFs,
no reports regarding the rate of MDMA use at EDMFs are available, although one study
reported a 5.4% prevalence of “amphetamines/MDMA” in drug assays among patrons exiting
San Francisco clubs with electronic dance music events (7).
Limited information exists regarding rates of hospital admissions and deaths at EDMFs
to compare with rates from the 2013 festival A. One published investigation was conducted
in Los Angeles after the death of an attendee at a New Year’s Eve EDMF (4). In NYC,
adverse health events at music festivals have not been routinely reported to DOHMH.
However, during the summer of 2012, two ED physicians reported to DOHMH that multiple
persons requiring ICU admission had been transported from an EDMF. As a result, DOHMH
initiated surveillance for adverse events at EDMFs, which detected the two deaths
at festival A in 2013. EDMF organizers were asked to report to DOHMH every 4 hours
the number of medical tent visits and attendees transported to EDs. Hospitals were
alerted in advance and reminded to report drug poisoning to the NYC Poison Control
Center, and DOHMH syndromic surveillance of EDs was modified to identify visits relating
to drug use and overdose.
The death rate associated with festival A in 2013 was found to be much higher than
that for unintentional poisoning deaths from all psychoactive substances in a comparable
NYC age group during 2012. However, without toxicology comparisons, it cannot be determined
whether methylone, a compound chemically similar to MDMA with both stimulant and hallucinogenic
properties and similar adverse effects, might have been the cause of the higher than
expected mortality (8).
DOHMH has developed recommendations to mitigate the risk for adverse events at future
EDMFs, including restricting admission to persons aged ≥18 years, employing strategies
to reduce excess alcohol consumption, prohibiting the sale of mixed energy-alcohol
drinks, providing readily accessible no-cost drinking water, identifying impaired
patrons and bringing them to medical attention (e.g., by using roaming teams and visual
inspections of attendees at entrances and exits), developing a plan to prevent heat-related
illness for summer events, distributing harm-reduction messages in advance of and
during events; and implementing a surveillance system to rapidly identify adverse
health events including reporting ED transports to DOHMH every 4 hours.
Festival A was held again in 2014 in NYC over the Labor Day weekend. The outdoor heat
index was 80°F–90°F, and there were ≤ 25,000 attendees each day. At this year’s festival
A, promoters with DOHMH consultation instituted and strengthened a number of safety
measures, including roaming teams of peer volunteers (one per 500 attendees), stricter
entrance procedures (denying admission to ticket holders visibly under the influence
of drugs or alcohol), procedures to reduce heat exposure (reduced festival hours),
and required viewing of harm reduction messages before entering the festival. The
DOHMH surveillance system identified 10 cases from festival A this year, including
two severe cases and one death. The death was attributed to use of methamphetamine.
The death occurred several hours after the event had closed for the day; future mitigation
strategies might include enhanced supervision of patrons leaving the venue.
The findings in this report are subject to at least three limitations. First, data
regarding adverse events or drug use for attendees not requiring ED transport were
unavailable. It is known that a substantial number of persons were treated on-site
and that certain persons would likely have been transported to EDs had medical treatment
tents not been available. Second, information regarding additional risk factors (e.g.,
physical exertion, amount and frequency of drug and alcohol use, and intake of caffeine,
water, and food) was limited. Third, biologic specimens were not available from all
patients for external testing; for these untested patients, drug use was defined on
the basis of a medical record report, which might have resulted in misclassification
of the exposure. Of six patients not tested for alcohol, two reported alcohol use
in the medical record. Of five patients without external toxicology testing, one reported
MDMA use in the medical record.
What is already known on this topic?
MDMA (3,4-methylenedioxymethamphetamine), also known as ecstasy or molly, is an amphetamine
derivative that has both stimulant and hallucinogenic effects. Although MDMA is an
illicit substance, it is used recreationally, including at electronic dance-music
festivals, and can cause adverse health events.
What is added by this report?
The New York City Department of Health and Mental Hygiene investigated adverse events
resulting in emergency department visits among persons who attended an electronic
dance-music festival held August 31–September 1, 2013 in the city. The investigation
identified 22 cases of adverse events; nine were severe, including two deaths. Twenty-one
of 22 patients had used drugs or alcohol. Of 17 patients with toxicology testing,
MDMA and other compounds were identified, most frequently methylone, in 11 patients.
What are the implications for public health practice?
As a result of this investigation, the New York City Department of Health and Mental
Hygiene and festival promoters developed multiple interventions including implementing
a surveillance system for adverse events and safety measures (e.g. roaming teams of
peer volunteers, stricter entrance procedures, procedures to reduce heat exposure,
and required viewing of harm reduction messages before entering the festival). These
interventions might help prevent adverse health events at future electronic dance-music
festivals in New York City and elsewhere.
Depending on applicable state and local laws, health departments might have a role
in issuing permits, determining medical service requirements, recognizing adverse
health events, and guiding harm reduction messaging at EDMFs. Further study is needed
of risk factors that might modify rates of adverse health events from EDMFs. In addition,
study of other mass-gathering events could provide data for comparison with EDMFs.