Exploring the Utility and Appropriateness of Dose Thresholds for Issuing of Public Drug Alerts on High‐Dose MDMA: A Qualitative Study

ABSTRACT

Introduction

Drug alerts are sometimes issued when samples are found to exceed a pre‐determined dose threshold. In Australia, it is common for alerts to be issued when MDMA pills contain ≥ 150 mg of MDMA free‐base or 179 mg hydrochloride. Nineteen such alerts were issued in Australia in 2024, raising concerns that repeat alerts may lose impact over time. This study examined experts' viewpoints on the appropriateness and utility of using a 150 mg threshold to trigger high‐dose MDMA alerts.

Methods

Fifteen participants responsible for the design and dissemination of drug‐alerts in Australia completed an online survey and seven participated in a focus group. The survey and focus group elicited reflections on the use of thresholds when issuing alerts about high‐dose MDMA. Data were thematically analysed using a qualitative description methodology.

Results

Although thresholds are binary and cannot account for evolving trends in MDMA manufacture or consumption, most agreed that 150 mg free‐base is a reasonable threshold for issuing alerts. It was noted that 150 mg of MDMA may cause harm, that high‐dose alerts are contingent on a threshold, and that thresholds enable rapid communications. Due to Australia's limited capacity to monitor community perceptions of alerts, there was little evidence to justify a change in the threshold.

Discussion and Conclusions

Notifying communities about products containing ≥ 150 mg MDMA remains a harm‐reduction priority. Establishing a database containing dosage and purity results for all analytically tested samples and increasing efforts to monitor community responses to and perceptions of drug alerts may improve future risk communication.

1. Introduction

Drug alerts are risk communications about acute harms arising from unregulated drug markets. Alerts may communicate information on adulterated or high potency drugs that carry an elevated risk [1]. Their purpose is to inform people who use drugs, service providers and wider communities about emerging concerns while promoting the adoption of harm reduction strategies [1, 2]. Alerts are most effective when they deliver actionable messages that are aligned with the priorities of people who use drugs and are issued by trusted and credible sources [3]. In this paper, we use the term drug alerts as an umbrella term for urgent drug‐related risk communications; we do so with acknowledgement that Australian agencies use a variety of terms when describing such communications; terms include drug notices, public drug warnings and community drug notices [1].

In Australia, 392 MDMA related deaths were recorded in the National Coronial Information System between 2001 and 2018 [4], with evidence from roughly the same time period denoting 38 MDMA related deaths following music festival attendance [5]. Data collected among a convenience sample of 5155 Australian festival attendees in late 2018 found that 79.5% reported MDMA use in the previous 12 months [6]. Among the 6.4% of these participants who had required festival‐based medical treatment in the previous 12 months, MDMA was frequently involved [7] and those seeking medical attention after MDMA use reported a median intake of three MDMA pills [7]. This evidence concords with earlier findings from a cross‐sectional web‐based survey of Australian festivalgoers which found that almost half (48%) of respondents who used MDMA pills reported consuming two drugs (typically two pills) simultaneously [8].

MDMA‐related deaths, alongside evidence of riskier consumption practices, highlight the need for tailored MDMA harm reduction interventions. While high‐dose MDMA alerts are an important harm reduction strategy, issuing alerts too frequently or in response to concerns perceived as low priority might lead to ‘alert fatigue’. A condition in which impact is diminished and the credibility of issuing agencies is undermined [2, 9, 10].

Much evidence on alert fatigue comes from other disciplines such as primary health care [11, 12] or environmental disasters [13]. In the context of drug use, little is known about the point at which alert fatigue may set in, or when concern about alert fatigue outweighs the benefits of providing information to those at risk. Very few participants in a 2023 cross‐sectional online survey conducted among people who use drugs in Australia reported experiencing alert fatigue; however, these data were collected during the early stages of Australian jurisdictions issuing drug alerts [14]. Cognisant of the potential to induce alert fatigue, agencies usually only issue drug alerts based on credible information about concerns that pose a verifiable risk [1, 3].

In Australia, some agencies issue risk communications about pressed pills containing a ‘high‐dose’ of MDMA, with high‐dose usually defined as ≥ 150 mg free‐base or 179 mg hydrochloride (HCl) [15, 16, 17]. This threshold is applied in New South Wales, and by the drug checking service CanTEST in the Australian Capital Territory [15, 16, 17]. Internationally, documentation regarding the use of thresholds is scarce. There is evidence of a 200 mg threshold applied in the context of European drug checking services; however, it is unclear whether this reporting threshold related to MDMA. HCl or free‐base [3], and there is no evidence that 200 mg represents a uniform reporting standard.

The supplement table included as Table S1 lists high‐dose MDMA alerts issued by Australian states and territories between 1 January 2024 and 30 June 2025. Throughout this period a total of 19 high‐dose MDMA alerts were issued, with alerts relating to 34 distinct pressed pills, with one alert over this period pertaining to samples in which a high‐dose of MDMA was detected alongside the synthetic cathinone dipentylone. Dose in all alerts was reported in free‐base, however, certain agencies and some people who use MDMA, communicate about MDMA dosage in terms of HCl salt [18, 19]. As outlined in O'Reilly et al., the HCl salt equivalent of free‐base MDMA dose is approximately 19% higher [20]. In our Table S1, we report dose in both free‐base and HCl, with dosages reported in recent Australian alerts ranging between 145 and 249 mg free‐base (173–296 mg HCl) and with an average dose of 188 mg (224 mg HCl) [15, 16, 17].

Drug alerts are time sensitive, so practitioners prioritise speed when designing and disseminating them [3]. The use of binary thresholds may streamline the process of issuing an alert but can also introduce additional complications. Namely, community understandings of ‘high‐dose’ are subjective, contextually specific and relative to manufacturing norms and consumption practices, which vary across jurisdictions and change over time [21]. Given this variability, issuing alerts on the basis of a fixed threshold risks the dissemination of alerts about dosages that may not be considered high among people who use MDMA, which may then threaten trust in alerts and the credibility of agencies who issue them [1]. However, this risk must be weighed against clinical evidence regarding a safer MDMA dose range. Research has shown that harms such as anxiety symptoms, transient severe hypertension and body temperature > 38°C become more likely with MDMA doses ≥ 125 mg HCl [22]. Further, a non‐linear dose exposure relationship has been observed. Small increases in MDMA dose equate to a disproportionate increase in MDMA plasma concentration, increasing the risk of acute toxicity [23]. The pharmacokinetics of MDMA are also non‐linear. Because MDMA inhibits the CYP2D6 enzyme, repeated or high doses lead to disproportionate increases in plasma concentrations beyond linear accumulation, thereby increasing risks associated with high or multiple doses [24].

While these risks illustrate an imperative to issue alerts about samples containing a high‐dose of MDMA, this imperative must be considered with regard for the variability of MDMA markets and normative consumption practices, the need for drug‐alerts to sustain their credibility among communities and the potential for alert fatigue. Despite these tensions, to our knowledge, no research has examined the utility or appropriateness of using thresholds to determine whether a drug alert should be issued. At the request of agencies across Australia who issue drug alerts about high‐dose MDMA, this study was conducted to explore: (i) the benefits and drawbacks of using fixed thresholds to issue alerts; (ii) the appropriateness of 150 mg MDMA free‐base as a benchmark for high‐dose; and (iii) approaches to improve risk communications about MDMA.

2. Methods

2.1. Participant Recruitment

This study was conducted by staff employed to manage the ‘Prompt Response Network’, a nationwide Australian practitioner network that comprises individuals who support the delivery of drug‐related monitoring and early warning initiatives across Australia's eight states and territories [25]. Purposively sampled participants were identified by the first three authors, who selected individuals with relevant expertise in drug alert design and dissemination in the Australian context. Study participants were invited to participate via a formal email invitation letter, with participation comprising two components: an initial survey, followed by an optional focus group.

2.2. Data Collection

The survey asked open‐ended questions to explore participants' practices and perceptions regarding alert design, moderation and the use of high‐dose thresholds. Following survey completion, seven participants also attended a 60‐min focus group which was conducted via Microsoft Teams and led by author J.F. The focus group explored preliminary survey findings in greater depth, with discussion spanning the utility of thresholds, perceptions of ‘alert fatigue’ and priorities for improved risk communication.

2.3. Data Analysis

The focus group was transcribed verbatim by author H.M. and data were analysed in alignment with a qualitative description methodology [26, 27]. Qualitative description is often used in healthcare research when a narrow phenomenon is under investigation, when data are collected among people with direct experience of this phenomenon and when research aims to inform local practice or policy [27].

In alignment with qualitative description methods, authors J.F. and H.M. familiarised themselves with the data by reading survey results and the focus group transcript prior to coding. Data were then inductively coded in NVivo 12. Together, J.F. and H.M. devised and interpreted five key theme areas and identified majority and discrepant views. Interpretations were reviewed by the authorship team, and a process of member checking was carried out with seven focus group attendees.

2.4. Reflexivity

This study was conducted by a team of researchers who are familiar with the process of designing and disseminating drug alerts and are active within the Australian drug monitoring and early warning sector more broadly. Prior qualitative research in Australia has demonstrated the ways in which familiarity with a subject matter and community may enhance understandings of how communities respond to and perceive drug alerts [28]. Further, literature on the subject of ‘insider research’ indicates that the pre‐existing content expertise and relationships with research participants may enable resonant and relevant studies, authentic data collection and easier access to relevant communities. However, insider status may also bias how questions are framed and data analysed while introducing ethical challenges associated with power and coercion [29, 30]. To mitigate these potential drawbacks, we invited external researchers to review our study design and research questions and conducted a thorough process of member checking post analysis. Our recruitment efforts emphasised the voluntary nature of research participation and our study underwent ethical review and received approval from UNSW HREC B: IRECS8002.

3. Results

The characteristics of 15 survey respondents and seven focus group attendees are shown in Table 1. Participants represented diverse disciplines and included senior staff from peer‐led organisations for people who use drugs, drug checking services, research bodies, government public health and forensic toxicology services.

TABLE 1.

Participant characteristics.

	Survey (n = 15)	Focus group (n = 7)
Jurisdiction
National a	2	0
Australian Capital Territory	1	2
Victoria	6	3
New South Wales	0	1
Queensland	4	1
Northern Territory	1	0
Western Australia	1	0
Tasmania	0	0
South Australia	0	0
Organisation type a
Drug checking service	6	4
Government public health department	2	2
Community organisation for people who use drugs	3	0
Forensic toxicology	2	0
Research	1	1
Advocacy and education	1	0

^a Participants coded as national either worked at peak organisations, or delivered services across multiple states and territories.

Five overarching themes emerged: (i) utility and limitations of thresholds; (ii) defining a high‐dose; (iii) alert fatigue; (iv) monitoring capacity; and (v) education priorities. These are summarised narratively below, with further detail and illustrative quotes provided in Table 2.

TABLE 2.

An overview of key themes by majority sentiment with consideration for caveats and discrepant viewpoints.

Theme	Majority sentiment	Quotes a	Caveats and discrepant views	Quotes a
Utility and limitations of thresholds	High‐dose MDMA alerts are contingent on thresholds, are pragmatic, and enable a binary‐criteria to determine whether an alert should be issued, support streamlined and enable expedited decision‐making.	‘If there is going to be high‐dose MDMA alerts, then we need to agree on what a high‐dose actually is, hence needing a threshold. Without one we are talking about different things, and it gets confusing’. (Researcher) ‘It allows for the streamlined assessment of samples’. (Researcher)	Thresholds mean little in the context of a dynamic and evolving unregulated drug market and issuing alerts based on them may eschew relevant factors such as the presence of adulterants, consumption practices and market norms.	‘The threshold conversation assumes that there is a degree of stability in the unregulated drug market that isn't there. It's completely subjective, because it's a piece of health communication, that needs to be considered in a local context, with changes sometimes rapidly being made based on new information (e.g., every tablet being over 200 mg)’. (Drug checking service representative)
2Defining high‐dose	The 150 mg threshold represents a dose which could cause toxicity and therefore doses above 150 mg entail risk. It is reasonable to sustain the 150 mg threshold for issuing high‐dose alerts, even though some may routinely dose more than 150 mg.	‘We shouldn't ‘pick winners’ when it comes to who may benefit from information for their personal risk assessment/harm reduction strategies. It's also worth remembering that people can experience harm from their “normal” MDMA dose, which may be as low as 70 mg (or even 150 mg in one dose), in hot conditions that are very typical to MDMA use contexts. For this reason, we should err toward a lower threshold’. (Government public health)	This threshold may be experienced by some as unduly alarmist and out of touch with market norms or community practices.	‘It's alarmist, and many people would enjoy 150 mg of MDMA on a night out. Alerting at this dose level makes government authorities look like wowsers and damages credibility when serious alerts need to be issued’. (Drug checking service representative)
3Alert fatigue	Concern that alerts are not reaching impacted communities. Noted that grading high‐dose MDMA alerts as ‘notices’ rather than ‘alerts may support risk stratification and diminish potential alert fatigue.	‘We disseminated a nitazene red alert in November last year and then we had clients going to get their methadone stuff from our government service … all of the doctors and every single nurse and even the facility manager had no idea that there was a nitazene in circulation, even though that was supposedly pushed out to the entire health sector. I just wanted to add that little anecdote around alert fatigue … if they're not receiving our reds [red community notices], they're certainly not reading our MDMA alerts’. (Drug checking service representative)	Noted possible high‐dose MDMA alert fatigue on Australia's eastern seaboard.	‘The utility of the threshold needs to be assessed based on the number of MDMA pills tested and the frequency of 150 mg + pills identified. Too many alerts reduce community engagement and impact and as it stands this I believe is happening across the east coast’. (Drug checking service representative)
4Monitoring capacity	Setting appropriate thresholds for high‐dose is contingent on the availability of close to real time data on substances that have undergone analytical testing. Noted that such a database should be publicly available, updated frequently and inclusive of all substances for which testing generates data on purity or dose, not just pressed pills.	‘We need to develop a national database of all drug samples that are analytically tested in Australia, and this should be publicly accessible’. (Researcher) ‘I think a repository of dosage could be useful. This way, cross‐service analyses can be undertaken (a bit like TEDI in Europe)’. (Drug checking service representative)	Concern raised about data temporality, noted that dashboards may quickly become out of date and propagate misinformation about drug markets.	‘So, establishing national databases sounds great, but there's going to be a lot of stuff that's maybe not that relevant, maybe even misleading. I always reflect on some of my European experiences where even drug checking services can't distinguish pills of the same press with completely different contents. So, we have to be careful with that level of information as well and the longevity that we think it has’. (Researcher) ‘If publicly available, clear messaging about products being variable, and not identifiable by eye/images is crucial. Similarly, it should be acknowledged that tested substances are only a small subset of the market—and may not reflect the entire market’. (Drug checking service representative)
5Education priorities	Suggested that alerts need be complimented by ongoing investment in education and communication efforts that promote harm reduction literacy.	‘Rather than focus on a threshold amount for a single dose unit like a pill, the study should seek to establish safer patterns of MDMA consumption by drug users … DIMS in the Netherlands provides advice on safer dosing, including a 1.0 mg to a maximum of 1.5 mg of MDMA base per kilogram of bodyweight per session. This corresponds to a maximum of approximately 100 mg for a 65 kg adult’. (Researcher)	NA	NA

^a Quotes are verbatim.

3.1. Utility and Limitations of Thresholds

Participants viewed high‐dose MDMA alerts as important communications, noting that such alerts are contingent on the existence of a defined dose threshold. The binary nature of thresholds was described as expediting the dissemination of time sensitive alerts. However, it was suggested that alerts issued on the basis of thresholds alone might overlook critical contextual circumstances. These circumstances were said to include market norms, consumer risk perceptions and harm reduction practices, the presence of adulterants, formulation type (e.g., slow vs. fast release), and environmental or circumstantial factors that may accentuate or mitigate harm. Additionally, one participant (Table 2, row 1) suggested that thresholds are arbitrarily applied and only applicable in the context of pressed pills, whereas most MDMA in Australia is now sold in powder or crystal form, often in capsules.

3.2. Defining ‘High‐Dose’

Two key agencies in Australia issue alerts based on a threshold of 150 mg MDMA free‐base. Our study did not collect data on the decision‐making processes that led to this initial determination regarding high‐dose, yet most agreed that 150 mg of MDMA free‐base (179 mg MDMA·HCl) poses a risk of harm or acute toxicity and is therefore a defensible threshold at which to issue an alert. However, some participants noted that MDMA‐related harm may occur at doses lower than 150 mg free‐base and felt that a lower threshold may be justified.

Certain participants reflected that high‐dose MDMA alerts have been criticised for not adequately accounting for common practices of dividing pills across multiple doses, as indicated by pill score lines. However, in response to this criticism, participants noted significant variation in harm reduction literacy among people who use MDMA. While some may know to divide pills, others do not, and withholding alerts was perceived to unduly disadvantage those without prior knowledge.

As reflected in Table 2, a minority of participants viewed the 150 mg definition of high‐dose as conservative or alarmist. One participant (Table 2, row 2) observed that response to MDMA dose is person dependent and that many people consume equal or higher amounts of MDMA without incident.

3.3. Alert Fatigue

It was acknowledged that Australia lacks capacity to monitor for responses to and perceptions of drug alerts. However, despite this acknowledgement, participants broadly rejected the idea that a state of alert fatigue in Australia had been realised. Instead, participants raised concerns that alerts were not reaching relevant communities. As noted in Table 2 (row 3), some participants spoke about circumstances in which even particularly urgent alerts relating to potent synthetic opioids had not reached people who use drugs. Counter to the predominant view that alert fatigue was not currently a pressing concern in Australia, two survey respondents remarked on a state of high‐dose MDMA alert fatigue being realised on Australia's eastern seaboard.

In order to satisfy community information needs while curbing concerns around alert fatigue, it was suggested by some participants that high‐dose MDMA alerts be issued not as ‘alerts’ but rather as communications denoting a lower level of risk than alerts. At the time of data collection, the Australian Capital Territory's drug checking service, CanTEST, had implemented a tiered communication strategy, issuing ‘yellow’ risk communications for high‐dose MDMA (and other moderate risk signals) and ‘red’ risk communications, which were reserved for signals perceived to represent a greater public health risk. Moreover, both CanTEST and NSW Health occasionally had combined multiple high‐dose MDMA detections into a single alert. Both strategies were narrated as potentially mitigating concerns regarding alert fatigue.

3.4. Monitoring Capacity

Participants suggested the possibility of adopting a more flexible approach to issuing risk communications on high‐dose MDMA to better enable communications to account for evolving market norms and consumption patterns. However, limited capacity to monitor markets close to real‐time was cited as a barrier to this approach. Arising from this discussion was the recognition that agencies who issue alerts may benefit from the establishment of a timely, accurate centralised database of analytical results from samples tested in Australia.

Participants felt that this database should contain analytically verified information on substance content, dose and purity, and that this database should be inclusive of all drugs, not just MDMA pills. It was suggested that this database may improve market monitoring to inform the issuance of drug alerts. Despite potential benefits, participants noted the dynamic and transient nature of unregulated markets in which the formulation of pills varies by batch and changes over time; as such, they were concerned that this database may propagate outdated or misleading information. Moreover, risks were said to be heightened by the inclusion of components like pill image libraries, with participants voicing concern that image libraries may spur the production of pills imitating those included in image libraries (copycat pills). Given these risks, the success of such a database was described as contingent on strong moderation protocols and explanatory disclaimers about the fact that markets rapidly change.

3.5. MDMA Education Priorities

Investment in community education on MDMA and harm reduction was unanimously supported. Priority topics for education included the additional risks associated with consuming stimulants in hot environments and the significance of score lines to indicate that a pill should be divided across multiple doses. Educating consumers about the relationship between dose and body weight was also seen as a priority, as was generating awareness about risks associated with using MDMA alongside other drugs, concerns around hydration and overheating.

4. Discussion

In a context of frequent high‐dose MDMA alerts [15–17], this study was prompted by queries regarding the appropriateness of defining high‐dose as ≥ 150 mg free‐base and the use of this as a threshold for issuing alerts. Our study was conducted among practitioners who design and disseminate drug alerts and our participants broadly indicated that a threshold of approximately 150 mg free‐base (179 mg HCl) is reasonable, with it noted that these doses are associated with potential harm [22, 23, 24] irrespective of prevailing market norms or consumption patterns.

Our participants' support for the ongoing issuance of high‐dose MDMA alerts accords with evidence indicating the ability of such alerts to enhance risk perception and promote harm reduction intentions. A recent Australian study using hypothetical scenarios found that individuals who were shown a drug alert about high‐dose MDMA were more likely to report intentions to avoid using the drug compared to those who were told they might possess high‐dose MDMA without being shown an alert [21]. While most of our participants did not believe that a state of alert‐fatigue had been realised in Australia, advising of multiple high‐dose MDMA detections within a single alert or demarcating these communications as being less urgent than other types of alerts were articulated as strategies which may curb the potential for fatigue. Our findings highlight an overall imperative to continue investing in MDMA harm reduction education and alongside alerts, our participants reflected the importance of sustained efforts to disseminate nuanced and MDMA specific harm reduction messaging.

Consistent with findings from Australian research on drug alerts which have denoted minimal concern around alert fatigue [14], overall participants in our study did not perceive evidence of alert fatigue. Rather than expressing concern about overexposure, respondents emphasised the importance of expanding the reach and visibility of alerts to ensure wider community awareness about the potential for high‐dose products. However, because our study was conducted among practitioners, our findings must not be considered representative of people who use MDMA and we note that further research with a focus on consumer perceptions of MDMA related harms, high‐dose and drug‐alerts must be conducted.

Our findings must be interpreted with regard for evidence of MDMA related harms in the Australian context and current MDMA market norms. In Australia, numerous deaths have been linked to MDMA toxicity [4, 5] and there is evidence of ‘double dropping’ and other risky consumption practices in festival settings [7, 8]. Moreover, a study from New South Wales, which presented quantitative data on MDMA pressed pills seized at music festivals in 2019, recorded a median free‐base per tablet of 116 mg (138 mg HCl) and a range of 24–201 mg (26–239 mg HCl) [20]. A similar study of seized samples in Queensland between 2017 and 2020 recorded an average free‐base of 56.7 mg per tablet (67 mg HCl), with the highest dose detection containing 209 mg free‐base (249 mg HCl) [31]. By comparison, a dosage survey of 1380 pills submitted for lab testing in the Netherlands recorded an average free‐base of 137 mg (163 mg HCl) [19]. This higher average dose concords with evidence from the wider European context in which a trend towards higher‐dose MDMA pills has been observed [32].

As observed in Europe [18], Australian agencies adopt varied approaches in terms of measuring and communicating about MDMA dose in either free‐base or MDMA HCl [33, 34, 35]. Certain Australian agencies who issue alerts use ultra‐performance liquid chromatography photodiode array (UPLC‐PDA) to identify and quantify MDMA in drug samples [36]. While conventional UPLC will determine MDMA quantity, it cannot determine the original MDMA salt form [36, 37]. In Australia, the decision by some organisations to provide MDMA quantities in terms of free‐base reflects a favouring of certainty, reporting simply what was analytically determined; the quantity of free‐base MDMA. The decision of other agencies to report MDMA quantities in terms of MDMA HCl favours the interpretability of alerts for consumers whose reference to MDMA quantity likely reflects purchasing and measuring dry quantities of MDMA (i.e., in salt form). This approach requires converting the free‐base amount measured by UPLC into an equivalent MDMA HCl dose. If the original sample contained an MDMA salt other than MDMA HCl (e.g., MDMA sulphate), the calculated quantity may not accurately represent the true MDMA content. Our study did not set out to explore the relative advantages or disadvantages associated with measurement and communication of MDMA dose in terms of free‐base or salt; however, such questions warrant further exploration.

Our study has several limitations. We engaged a relatively small group of 15 practitioners, mainly located along Australia's eastern seaboard, the Australian region best resourced to detect and respond to emerging drug concerns and where the most frequent MDMA alerts have been issued [15–17]. As such, our findings do not sufficiently reflect experiences and perspectives across all Australian states and territories. Further, our study adopted a narrow focus on the issuance of high‐dose MDMA alerts and our data do not address a range of relevant questions that ought to be prioritised in future research. First, agencies who issue alerts in Australia commonly alert about instances of adulteration and substitution, with many alerts warning about the presence of potentially dangerous new psychoactive substances [15, 16, 17]. Future research must explore mechanisms for investigating signals of concern and processes associated with issuing alerts associated not only with high‐dose, but also in instances of adulteration or substitution. Second, as earlier noted, our research focussed on practitioners and our findings indicate that further research to explore how communities understand, perceive and respond to communications about high‐dose MDMA and other alerts is warranted.

5. Conclusions

High‐dose MDMA alerts were regarded as contingent on the existence of a threshold for high‐dose, and most participants agreed that defining high‐dose at ≥ 150 mg free‐base (179 mg HCl) is appropriate. The development of a database of analytically tested drug samples, displaying close to real‐time information, was recommended; several similar databases connected to drug checking services operate across diverse jurisdictions globally [38]. Additionally, respondents strongly supported broader investment in population‐wide harm reduction education related to MDMA. Bundling multiple high‐dose detections into one drug alert and making use of tiered alert systems, with high‐dose MDMA alerts treated as representing lower risk than detections of, for example, potent synthetic opioids, may provide communities with information while reducing the potential for alert fatigue.

Author Contributions

J.F. led conceptualisation, data collection, data analysis and writing of the original draft, H.M. supported conceptualisation, data collection, data analysis and reviewing and editing of the final manuscript. S.K. supported conceptualisation, reviewing and editing of the final manuscript. B.C., K.J.S. and N.E. supported conceptualisation, supervision, reviewing and editing of the final manuscript.

Funding

This project was funded by the National Centre for Clinical Research on Emerging Drugs, which receives funding from the Australian Department of Health, Disability and Ageing.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Table S1: High‐dose MDMA alerts issued in Australia in 2024 and to 30 June 2025.

Data Availability Statement

Research data are not shared.