Deconstructing Ecstasy: The Politics Of Mdma Research

Psychedelic Science, Contemplative Practices, and Indigenous and Other Traditional Knowledge Systems: Towards Integrative Community-Based Approaches in Global Health

As individuals and communities around the world confront mounting physical, psychological, and social threats, three complimentary mind-body-spirit pathways toward health, wellbeing, and human flourishing remain underappreciated within conventional practice among the biomedical, public health, and policy communities. This paper reviews literature on psychedelic science, contemplative practices, and Indigenous and other traditional knowledge systems to make the case that combining them in integrative models of care delivered through community-based approaches backed by strong and accountable health systems could prove transformative for global health. Both contemplative practices and certain psychedelic substances reliably induce self-transcendent experiences that can generate positive effects on health, well-being, and prosocial behavior, and combining them appears to have synergistic effects. Traditional knowledge systems can be rich sources of ethnobotanical expertise and repertoires of time-tested practices. A decolonized agenda for psychedelic research and practice involves engaging with the stewards of such traditional knowledges in collaborative ways to codevelop evidence-based models of integrative care accessible to the members of these very same communities. Going forward, health systems could consider Indigenous and other traditional healers or spiritual guides as stakeholders in the design, implementation, and evaluation of community-based approaches for safely scaling up access to effective psychedelic treatments.

Serotonin toxicity of serotonergic psychedelics

RATIONALE

In recent years, psychedelic substances with serotonergic mechanisms have accumulated substantial evidence that they may provide therapeutic benefits for people suffering with psychiatric symptoms. Psychiatric disorders targeted by these psychedelic-assisted therapies are managed with serotonergic drugs like selective serotonin reuptake inhibitors (SSRIs) as the current standard of care, so it is important to evaluate the potential risks of drug-drug interactions and serotonin toxicity (ST) between these agents.

OBJECTIVES

A critical evaluation of the scientific literature is necessary to delineate the risks of ST when combining psychedelics with available serotonergic pharmacotherapy options. This review article describes signs and symptoms of ST, characterizes mechanisms of ST risk, summarizes what is known about serotonergic psychedelic drug interactions, and outlines potential management strategies.

RESULTS

True ST typically occurs with a serotonergic drug overdose or in combinations in which a drug that can increase intrasynaptic serotonin is combined with a monoamine oxidase inhibitor (MAOI). Serotonergic psychotropics that do not contain MAOIs are low risk in combination with psychedelics that also do not contain MAOIs. Signs and symptoms warranting immediate medical attention include myoclonus, extreme and fluctuating vital signs, agitation or comatose mental state, muscle rigidity, pronounced hyperthermia (fever), and/or seizure activity.

CONCLUSIONS

Serotonin-related adverse reactions exist along a spectrum with serotonin syndrome being the most severe manifestations of ST. Due to varying serotonergic mechanisms of psychedelics and psychotropics, with varying propensities to increase intrasynaptic serotonin, some combinations may present a significant risk for serotonin toxicity (ST) while others are likely benign.

MDMA Is Not Ecstasy: The Production of Pharmaceutical Safety through Documents in Clinical Trials

Nonprofit efforts to develop ±3,4-methylenedioxymethamphetamine (MDMA)-better known as the street drug Ecstasy-as a prescription pharmaceutical provide the opportunity to examine recent theorizations of pharmaceuticals as fluid objects transformed in new informational and material environments. Drawing from ethnographic research, this article interrogates MDMA researchers' own distinction between MDMA and the street drug Ecstasy. While researchers maintain that pure MDMA is distinct from Ecstasy, this article argues that the difference between the two hangs not on a distinction in substance, but on a distinction in safety that must be produced through the trial. This article tracks the production of safety through the inter-connected work of clinical documents, which manage both which bodies are allowed to absorb the drug and which bodily events count as effects. MDMA's safety emerges from the careful management of relations through these documentary practices.

Intersectional insights from an MDMA-assisted psychotherapy training trial: An open letter to racial/ethnic and sexual/gender minorities

The road to the current psychedelic renaissance in research on ±3,4-methylenedioxymethamphetamine (MDMA) – the active ingredient of the drug Ecstasy – for addressing treatment-resistant post-traumatic stress disorder has been fraught with political and academic bias, as well as cultural stigma among underserved populations, all of which serve as barriers to minority inclusion and participation. In this open letter to ethnic/racial and sexual/gender minorities, the author details intersectional insights from his own experience being administered MDMA legally as part of a therapist training trial for MDMA-assisted psychotherapy, in hopes of radically destigmatizing this treatment approach for marginalized populations. Themes covered include: set and setting; cultural pride; LGBTQIA+ pride; acceptance of intersectionality; and patience, perspective, and strength in retrospection. This letter concludes by tasking current investigators of MDMA-assisted psychotherapy to emphasize issues of intersecting identities (e.g., in terms of race, ethnicity, sexual orientation, and gender identity) in their research agenda, attempt to improve minority participation in a culturally attuned manner, as well as increase minority stakeholdership in this field.

The psychedelic renaissance and the limitations of a White-dominant medical framework: A call for indigenous and ethnic minority inclusion

In recent years, the study of psychedelic science has resurfaced as scientists and therapists are again exploring its potential to treat an array of psychiatric conditions, such as depression, post-traumatic stress disorder, and addiction. The scientific progress and clinical promise of this movement owes much of its success to the history of indigenous healing practices; yet the work of indigenous people, ethnic and racial minorities, women, and other disenfranchised groups is often not supported or highlighted in the mainstream narrative of psychedelic medicine. This review addresses this issue directly: first, by highlighting the traditional role of psychedelic plants and briefly summarizing the history of psychedelic medicine; second, through exploring the historical and sociocultural factors that have contributed to unequal research participation and treatment, thereby limiting the opportunities for minorities who ought to be acknowledged for their contributions. Finally, this review provides recommendations for broadening the Western medical framework of healing to include a cultural focus and additional considerations for an inclusive approach to treatment development and dissemination for future studies.

The spurious relationship between ecstasy use and neurocognitive deficits: A Bradford Hill review

Numerous studies have suggested that MDMA can cause neurocognitive deficits. However, the available data can only suggest an association - rather than a causal relationship - between MDMA use and neurocognitive deficits. The reliability and robustness of this association was evaluated using Bradford Hill's criteria for determining causation in epidemiology research. Several limitations in the literature were found. Studies have recruited people who abuse ecstasy - an illicit drug that does not always contain MDMA. There is inherent risk in consuming impure or falsely identified substances; and using this as a source as for scientific opinion may introduce biases in our understanding the actuals risks associated with MDMA. Importantly, given that ecstasy research is predominately retrospective, baseline functioning cannot be established; which may be influenced by a variety of preexisting factors. Many studies introduce statistical errors by inconsistently dichotomizing and comparing light and heavy ecstasy users, making dose-response relationships inconclusive. When interpreting the ecstasy literature effect sizes are a more meaningful indicator of neurocognitive functioning rather than relying on p-values alone. Most meta-analyses have failed to find clinically relevant differences between ecstasy users and controls. There is also consistent evidence of publication bias in this field of research, which indicates that the literature is both biased and incomplete. Finally, suggestions for improving the ecstasy literature are provided.

Novel psychopharmacological therapies for psychiatric disorders: psilocybin and MDMA

4-phosphorloxy-N,N-dimethyltryptamine (psilocybin) and methylenedioxymethamfetamine (MDMA), best known for their illegal use as psychedelic drugs, are showing promise as therapeutics in a resurgence of clinical research during the past 10 years. Psilocybin is being tested for alcoholism, smoking cessation, and in patients with advanced cancer with anxiety. MDMA is showing encouraging results as a treatment for refractory post-traumatic stress disorder, social anxiety in autistic adults, and anxiety associated with a life-threatening illness. Both drugs are studied as adjuncts or catalysts to psychotherapy, rather than as stand-alone drug treatments. This model of drug-assisted psychotherapy is a possible alternative to existing pharmacological and psychological treatments in psychiatry. Further research is needed to fully assess the potential of these compounds in the management of these common disorders that are difficult to treat with existing methods.

MDMA-assisted therapy: A new treatment model for social anxiety in autistic adults

The first study of 3,4-methylenedioxymethamphetamine (MDMA)-assisted therapy for the treatment of social anxiety in autistic adults commenced in the spring of 2014. The search for psychotherapeutic options for autistic individuals is imperative considering the lack of effective conventional treatments for mental health diagnoses that are common in this population. Serious Adverse Events (SAEs) involving the administration of MDMA in clinical trials have been rare and non-life threatening. To date, MDMA has been administered to over 1133 individuals for research purposes without the occurrence of unexpected drug-related SAEs that require expedited reporting per FDA regulations. Now that safety parameters for limited use of MDMA in clinical settings have been established, a case can be made to further develop MDMA-assisted therapeutic interventions that could support autistic adults in increasing social adaptability among the typically developing population. As in the case with classic hallucinogens and other psychedelic drugs, MDMA catalyzes shifts toward openness and introspection that do not require ongoing administration to achieve lasting benefits. This infrequent dosing mitigates adverse event frequency and improves the risk/benefit ratio of MDMA, which may provide a significant advantage over medications that require daily dosing. Consequently, clinicians could employ new treatment models for social anxiety or similar types of distress administering MDMA on one to several occasions within the context of a supportive and integrative psychotherapy protocol.

Patterns of polydrug use in Great Britain: findings from a national household population survey

BACKGROUND

Polydrug use potentially increases the likelihood of harm. As little is known about polydrug use patterns in the general population, it is difficult to determine patterns associated with highest likelihood.

METHODS

Latent class analysis was performed on nine illicit substance groups indicating past year use of cannabis, cocaine, amphetamines, ecstasy, LSD, mushrooms, amyl nitrate, tranquillisers and heroin or crack. Analyses were based on data from a large multi-stage probability sample of the population of Great Britain (n=8538) collected in 2000. Multinomial logistic regression was performed highlighting associations between classes, and demographic and mental health variables.

RESULTS

A three class solution best described patterns of polydrug use; wide range, moderate range, and no polydrug use. For males and young people, there was a significantly increased chance of being in the wide and moderate range polydrug use groups compared to the no polydrug use class. Hazardous drinking was more likely in the wide and moderate polydrug classes with odds ratios of 9.99 and 2.38 (respectively) compared to the no polydrug use class. Current smokers were more likely to be wide and moderate range polydrug users compared to the no polydrug use class with odds ratios of 4.53 and 5.85 respectively. A range of mental health variables were also related to class membership.

CONCLUSIONS

Polydrug use in Great Britain can be expressed as three distinct classes. Hazardous alcohol use and tobacco use were strongly associated with illicit polydrug use, polydrug use appeared to be significantly associated with mental health, particularly lifetime suicide attempts.

Recreational ecstasy use and the neurotoxic potential of MDMA: current status of the controversy and methodological issues

The controversy over possible MDMA-induced serotonergic neurotoxicity in human recreational ecstasy users is examined critically in light of recent research findings. Although the designs of such studies have improved considerably since the 1990s, the evidence to date remains equivocal for a number of reasons, including (1) inconsistent findings on the existence and reversibility of persistent ecstasy-related serotonergic and cognitive deficits; (2) lack of clear association between changes in brain imaging measures and functional deficits attributed to MDMA-induced neurotoxicity; (3) the contribution of concomitant cannabis or other drug use to both brain imaging abnormalities and cognitive deficits; (4) methodological shortcomings such as failure to adequately match samples of ecstasy users and controls; (5) the questionable relevance of animal models of MDMA-induced neurotoxicity to typical human patterns of ecstasy use; and (6) the potential role of inherent pre-drug deficits in serotonergic systems, impulse control and executive cognitive function that may predispose to excessive use of drugs including ecstasy. Given the retrospective nature of nearly all studies of ecstasy users to date, the controversy over whether MDMA has ever caused neurotoxicity or cognitive deficit in human ecstasy users is likely to continue for some time without resolution.

Consuming e: Ecstasy Use and Contemporary Social Life

Research and popular commentary on Ecstasy often frames users as rebellious youth reacting against mainstream society via hedonistic rave parties and reckless intoxication. Critical consideration of the complex social and economic foundations of Ecstasy use is lacking in much of this youth-based research. Growing evidence, for example, suggests that a wide range of people take Ecstasy in a variety of contexts. Through the lens of anthro-economic approaches to consumption this article suggests that although Ecstasy is an illicit drug popular among youth, the symbolic meanings surrounding its use are also connected to the every-day. Accounts of 12 Ecstasy users from Canberra, Australia show how their experiences of Ecstasy, and the value the drug gives to their social relations, are firmly situated within the aspirations and confines of late capitalist consumer society. Participants' narratives were associated with ideologies about vitality, leisure and the importance of being social and energetic without impinging on one's other social responsibilities. Their patterns of Ecstasy consumption were not only connected to subcultural tastes and desires but changing values of leisure and consumption in wider contemporary life.

Poly-Drug Use among Ecstasy Users: Separate, Synergistic, and Indiscriminate Patterns

The main objective of this paper is to explore poly-drug use among young adult ecstasy users. This phenomenon of using multiple substances within a specific time period is multi-faceted. In this paper, we focus on the various patterns of poly-drug use and the reasons for combining multiple drugs among ecstasy users. Using a mixed-methods design, we conducted interviews with young adults who used ecstasy and other licit and illicit drugs in the past 90 days. Based on the qualitative analyses, we define three distinct types of poly-drug experiences: separate, synergistic, and indiscriminate use. While separate and synergistic poly-drug use tended to be intentional, indiscriminate poly-drug use often was unintentional. These findings show the importance of recognizing poly-drug use as a common phenomenon. The findings presented here suggest areas for further research aimed at identifying risk and protective behaviors and risk reduction strategies.

A comparison of the physiological, behavioral, neurochemical and microglial effects of methamphetamine and 3,4-methylenedioxymethamphetamine in the mouse

3,4-Methylenedioxymethamphetamine (MDMA) and methamphetamine (METH) are amphetamine analogues with similar persistent neurochemical effects in the mouse which some have described as neurotoxicity. We attempted to identify dose regimens of MDMA and METH with similar effects on behavioral and physiological variables in the mouse, then quantified the effects of these dose regimens on neurochemistry and microglial markers. Four discrete injections of saline, MDMA (10, 20, or 30 mg/kg), or METH (5 or 10 mg/kg) were administered to mice at 2 h intervals. Body weight was quantified immediately before each injection, and 2 h after the last injection, while core temperature and locomotor activity were continuously monitored via radiotelemetry. Mice were killed 72 h after the final injection and brains were rapidly dissected on ice. Dopamine content in various brain regions was quantified via high pressure liquid chromatography (HPLC), and microglial activation was assessed by saturation binding of the peripheral benzodiazepine receptor (PBR) ligand 1-(2-chlorophenyl)-N-methyl-N-(1-methylpropyl)-3-isoquinoline carboxamide ([(3)H]PK11195). Specific dose regimens of MDMA and METH induced similar reductions in body weight, depletions of dopamine and its metabolites, and similar hyperthermic and locomotor stimulant effects, but only METH activated microglia in striatum. These results suggest that repeated high doses of MDMA and METH that produce hyperthermia, locomotor stereotypy, weight loss and neurochemical depletion are not consistently accompanied by microglial activation. The finding that METH, but not MDMA, induces microglial effects in the striatum consistent with neurotoxicity might imply different mechanisms of toxic action for these two psychostimulants.

Are there sex differences associated with the effects of ecstasy/3,4-methylenedioxymethamphetamine (MDMA)?

Sex has been identified as an important factor in moderating the effects of several drugs of abuse. Given the increasing popularity of ecstasy (3,4-methylenedioxymethamphetamine [MDMA]) use, it is important for researchers and clinicians to understand the factors that may influence its pharmacological actions to improve education, harm reduction and treatment efforts. This review focuses on preclinical and clinical research that examines the role of sex as an independent variable in the effects of ecstasy/MDMA. A systematic search of PsycINFO and MEDLINE electronic databases from 1966 to April 2006 was conducted. Both preclinical and clinical studies show a sexually dimorphic pattern in the acute, subacute and possibly long-term effects of ecstasy/MDMA. Specifically, adult females are more sensitive than males to the acute and subacute physical and psychological effects of ecstasy/MDMA and long-term alterations in aspects of 5-HT functioning. Conversely, males are more sensitive to the acute physiological effects of ecstasy/MDMA. These findings are consistent with research outcomes reported for other substances such as amphetamines and cocaine. Potential reasons for these sex differences and directions for future research are discussed.

Reinforcing effects of methylenedioxy amphetamine congeners in rhesus monkeys: are intravenous self-administration experiments relevant to MDMA neurotoxicity?

RATIONALE

Many animal models relevant to the persistent effects of drugs of abuse necessitate the application of interspecies dose scaling procedures to approximate drug administration regimens in humans, but drug self-administration procedures differ in that they allow animal subjects to control their own drug intake.

OBJECTIVES

This report reviews the reinforcing effects of 3,4-methylenedioxymethamphetamine (MDMA), its enantiomers, and several structural analogs in rhesus monkeys, paying particular attention to the pharmacological mechanisms of such reinforcing effects, the development of structure activity relationships among these compounds, the stability of MDMA self-administration behavior over time, and the persistent effects of self-administered MDMA on monoamines.

RESULTS

The methylenedioxy amphetamine congeners MDMA, 3,4-methylenedioxyamphetamine, N-ethyl-3,4-methylenedioxyamphetamine, and N-methyl-1-(3,4-methylenedioxyphenyl)-2-butanamine function as reinforcers in rhesus monkeys, maintaining self-administration behavior greater than that engendered by contingent saline but less than that engendered by traditional psychostimulants. These findings are remarkable as structurally distinct serotonergic hallucinogen-like drugs do not maintain reliable self-administration in laboratory animals. During prolonged MDMA self-administration, MDMA-maintained responding progressively weakens, and MDMA eventually fails to maintain significant self-administration. The neurochemical correlates of this effect have not yet been identified.

CONCLUSIONS

Procedures in which MDMA and related compounds are self-administered can be established in rhesus monkeys. These techniques can be used to engender contingent MDMA exposure without resorting to controversial methods of interspecies dose scaling. As such, further application of self-administration methods may provide important new insights into the persistent effects of MDMA on brain and behavior in nonhuman primates.

Drug use practices among MDMA/ecstasy users in Ohio: a latent class analysis

This study describes the drug use practices among 402 recent MDMA (3,4-methelyenedioxymethamphetamine) users recruited in Ohio using respondent-driven sampling. About 64% of the participants were men, 81.6% were white, and the mean age was 20.9 years. Latent class analysis was used to identify subgroups of MDMA users. Use of cocaine, opioids, amphetamines, tranquilizers, inhalants, marijuana, and hallucinogens during the previous 6 months, and days of "drunkenness" in the past 30, were used for classification. A three-class model was preferable and reflected "Limited range," "Moderate range," and "Wide range" drug use patterns. For example, the conditional probability of using opioids during the previous 6 months was .07 in Class 1, .59 in Class 2, and .88 in Class 3. Other substances followed similar patterns. Predictors of class membership were examined in a multinomial logit model in which the "Limited range" Class was treated as the reference group. Participants who were white, younger, and who reported more than 10 occasions of MDMA use were more likely to be in the "Wide range" drug use Class. Latent class analysis is a useful method to help describe and understand variability in polydrug use patterns.

MDMA/Ecstasy Use Among Young People in Ohio: Perceived Risk and Barriers to Intervention

In the past several years, the use of MDMA (Ecstasy) has increased substantially in the United States and in many countries around the world. Although this increase has been associated with the dance club and rave scenes, Ecstasy use has expanded into new settings. At the same time, the diversity of people using the drug has also grown. Given the increasing, although unclear, evidence that MDMA has the potential to cause neurotoxicity and various psychological problems under certain conditions among humans, understanding how active users perceive the risks associated with Ecstasy use can help to inform prevention and intervention approaches. Based on audiotaped focus groups and individual interviews conducted with 30 Ecstasy users in Dayton and Columbus, Ohio, this article explores these and other issues. Results demonstrate that beyond the risk of obtaining something potentially deadly instead of MDMA, most users do not associate risks of neurotoxicity or psychological problems with Ecstasy use. Active users look to harm-reduction approaches for answers to using Ecstasy safely; prevention messages like, "just say no to drugs" are largely ignored. Because Ecstasy is commonly used among small groups of friends, peer leader or other social network intervention approaches may be promising.

Sources of information about MDMA (3,4-methylenedioxymethamphetamine): perceived accuracy, importance, and implications for prevention among young adult users

The goal of this cross-sectional study was to assess the perceived accuracy and the importance of various sources of information about MDMA/ecstasy among young adult users. A respondent driven sampling plan was used to recruit a community sample of recent ecstasy users (n = 304), aged 18-30, in Ohio, who responded to structured interviews. Friends, drug abuse treatment programs, and physicians were perceived to be the most accurate sources of information about ecstasy by 45.7, 37.2, and 30.3% of the sample, respectively. Friends were considered the most important source of information about ecstasy (40.2%), followed by web sites like DanceSafe (16.2%), and MTV/VH1 television specials (6.9%). About half the sample used the Internet to obtain information about ecstasy, with younger and more educated participants significantly more likely to do so. Educated users were also significantly more likely to consider the Internet to be an important source of information. Web sites like DanceSafe were visited by four times as many users as government-sponsored web sites. Findings support the development of peer-oriented, network strategies to reach ecstasy users with prevention messages. Efforts to make prevention web sites more attractive should be considered.

Quitting ecstasy: an investigation of why people stop taking the drug and their subsequent mental health

The regular use of ecstasy (3,4-methylenedioxymethamphetamine, MDMA) has been associated with depressed mood, anxiety and hostility, but it is not known whether such effects persist after people stop using the drug. Furthermore, little is known about what factors might influence the decision to quit using MDMA. The aim of the present study was to examine the reasons why ex-users had stopped using this drug and to assess their current levels of depression, anxiety, anger and aggression. Telephone interviews were conducted with people who used to take MDMA on a regular basis but who no longer used the drug. The participants comprised sixty-six ex-users who used to take MDMA regularly (at least once every 2 months over a period of at least 1 year), but who had not taken MDMA for at least 1 year (average 3 years). Participants were asked about why they had quit MDMA. They also completed questionnaires to assess trait mood. Ex-users could be divided into two groups based on their reason for quitting: (i) those who had quit for mental health reasons and (ii) those who had quit for circumstantial reasons. Approximately half of those in the mental health group scored in the range for clinical depression. In that group, current levels of depression and anxiety correlated significantly with the cumulative amount of MDMA that they had taken several years previously. These findings suggest that some users may either be more vulnerable to the adverse effects of MDMA or have pre-existing mental health problems for which they self-medicate by using ecstasy. The present study shows that some ex-users experience an impairment to mental health that persists for years after they stop using this drug.

Altered states: the clinical effects of Ecstasy

Ecstasy is the second most widely abused illegal drug in Europe. Ecstasy is the colloquial name for 3,4-methylenedioxymethamphetamine (MDMA), but not all Ecstasy tablets contain MDMA. When taken in hot, crowded environments, Ecstasy/MDMA users have developed acute complications that have had fatal consequences. Epidemiological evidence indicates that adverse reactions to Ecstasy/MDMA intoxication are rare and idiosyncratic. Potential mechanisms of action are reviewed. In animal studies, MDMA damages serotonergic fibres and reduces the number of serotonin transporter sites within the CNS. Demonstration of neurotoxicity in human users of Ecstasy is hampered by a number of confounds that the majority of published studies have failed to address. These confounds are reviewed and their impact is discussed.

How strong is the evidence that brain serotonin neurons are damaged in human users of ecstasy?

Understanding the diverse functions of serotonin in the human brain can be obtained through examination of subjects having a lower than normal number of brain serotonin neurons. Behavioral abnormalities consistent with brain serotonergic damage have been reported in some polydrug users who also use the neurotoxin ecstasy (methylenedioxymethamphetamine, MDMA). This review evaluates the evidence from neuroimaging studies that brain serotonergic damage is a feature of human users of ecstasy. To date, neuroimaging studies designed to establish whether levels of brain serotonin neurons are lower than normal in ecstasy users have employed radioligands that bind to one component of the serotonin neuron, the serotonin transporter (SERT). Because these studies are methodologically flawed in terms of reliability or validity of the SERT measurement and appear to have employed polydrug users, no definitive information is yet available on the question of ecstasy toxicity to human brain serotonin neurons. Until these issues are resolved, it cannot be assumed that ecstasy exposure represents a chronic serotonin deficiency condition.

Ecstasy: America's new "reefer madness"

MDMA (3,4-methylenedioxymethamphetamine) was first used as a legal adjunct to psychotherapy in the 1970s. By the early 1980s, "Ecstasy" had become a tiny part of the recreational American drug scene, and was ultimately criminalized in 1986. For a decade use continued, but remained quiet. By the end of the 1990s, increased supply, demand, seizures of pills, arrests of distributors associated with organized crime, adverse reactions, and government reports of problematic brain changes created an Ecstasy media frenzy. The government's reaction led to a public education campaign and proposals for exponential penalties for production, distribution and use of MDMA. This article looks at the history, epidemiology, and politics of Ecstasy, the media's response, and the ways in which media and government reaction will compromise harm reduction and safety.

Human psychopharmacology of Ecstasy (MDMA): a review of 15 years of empirical research

MDMA (3,4-methylenedioxymethamphetamine) or 'Ecstasy' was scheduled as an illegal drug in 1986, but since then its recreational use has increased dramatically. This review covers 15 years of research into patterns of use, its acute psychological and physiological effects, and the long-term consequences of repeated use. MDMA is an indirect monoaminergic agonist, stimulating the release and inhibiting the reuptake of serotonin (5-HT) and, to a lesser extent, other neurotransmitters. Single doses of MDMA have been administered to human volunteers in double-blind placebo-controlled trials, although most findings are based upon recreational MDMA users. The 'massive' boost in neurotransmitter activity can generate intense feelings of elation and pleasure, also hyperactivity and hyperthermia. This psychophysiological arousal may be exacerbated by high ambient temperatures, overcrowding, prolonged dancing and other stimulant drugs. Occasionally the 'serotonin syndrome' reactions may prove fatal. In the days after Ecstasy use, around 80% of users report rebound depression and lethargy, due probably to monoaminergic depletion. Dosage escalation and chronic pharmacodynamic tolerance typically occur in regular users. Repeated doses of MDMA cause serotonergic neurotoxicity in laboratory animals, and there is extensive evidence for long-term neuropsychopharmacological damage in humans. Abstinent regular Ecstasy users often display reduced levels of 5-HT, 5-HIAA, tryptophan hydroxylase and serotonin transporter density; functional deficits in learning/memory, higher cognitive processing, sleep, appetite and psychiatric well-being, and, most paradoxically, 'loss of sexual interest/pleasure'. These psychobiological deficits are greatest in heavy Ecstasy users and may reflect serotonergic axonal loss in the higher brain regions, especially the frontal lobes, temporal lobes and hippocampus. These problems seem to remain long after the recreational use of Ecstasy has ceased, suggesting that the neuropharmacological damage may be permament. Copyright 2001 John Wiley & Sons, Ltd.