Ecstasy - drug choice of the new generation: The medical viewpoint.

Susan P. Robbins, Ph.D., LMSW-ACP

During the past year there has been a great deal of media attention given to the designer drug ecstasy. Hailed as the "new party drug," stories about the dangers of club drugs, and ecstasy in particular, were widely publicized due in part to the increase in its use by adolescents and reports that it was easy to obtain. The term "club drug" is used to describe drugs that are commonly associated with dance parties or raves. Warnings about ecstasy's ability to cause death, permanent brain damage, and impaired memory and cognitive function became widely spread by government sources such as the National Institute on Drug Abuse and other agencies. It has been portrayed as a nationwide problem, serious health threat and an extremely dangerous drug that is increasingly associated with violence among drug dealers who are engaged in turf wars over its distribution.

Known on the street as Adam, XTC, X, E and rolls, ecstasy (3,4-methylenedioxymethamphetamine, or MDMA) is chemically related to both amphetamine and mescaline and was first discovered and patented by Merck in the early 1900s. Despite the early patent, it was never used clinically or tested on humans and it remained relatively unknown until the late 1970s, when it reemerged as a drug that was heralded by some psychotherapists as a "miracle drug" that could help patients achieve insight and empathy. By the early 1980s, ecstasy spread from the therapists' offices into bars throughout communities in Texas and the Pacific Northwest and its use became more prevalent among young adults. At the same time ecstasy was also becoming popular in England, particularly at "raves," or huge, all-night dance parties that were held in clubs, abandoned warehouses or other underground locations. The newly emerging rave scene in the U.S. followed suit and raving quickly became synonymous with rhythmic "techno" music and dancing, often while "tripping" or "rolling" on ecstasy.

In its pure form, ecstasy is a white crystalline powder that is most commonly made into a pressed pill, although it can also be sold in a capsule or as a loose powder. It is manufactured primarily in clandestine labs and the pills come in a variety of different shapes, sizes, and colors. As with all drugs that act in the brain to alter moods, thoughts and behaviors, its specific effects are dose-related, and it is typically taken orally in doses of 50-200 mg. In powder form, or as a crushed pill, it can be inhaled, and some users have also tried rectal administration. Although ecstasy can be injected, this is rarely done, and is extremely dangerous. Currently, the street price for a dose of ecstasy is usually between $20 and $30.

The initial effects of ecstasy can be felt within 30-40 minutes, peak levels are reached within an hour, subside gradually, and the effects may last from four to six hours. Similar to the effects of amphetamines and other stimulants, ecstasy produces a dilation of the pupils, decreased appetite, an increase in heart rate and blood pressure, a possible increase in body temperature, as well giving the user a feeling of increased energy and alertness. Abnormal eye movements that resemble the rapid squiggling movements made during Rapid Eye Movement sleep are common when the user is at the height of the MDMA experience. However, unlike the amphetamines, ecstasy can also produce profound subjective psychological effects that are unlike those of any other drug. These effects include increased feelings of self-worth, self-love and self-acceptance, and increased empathy, acceptance and love for others. It often creates a feeling of being calm, focused and centered and gives users a better sense of body awareness and posture. In addition, it decreases defensiveness and anxiety. For these reasons, it has been labeled an "enacotgen," a drug that generates a generalized feeling of peace and happiness, and an "empathogen," a drug that produces a feeling of emotional closeness to others.

Despite the seemingly positive psychological effects, ecstasy users can also experience adverse effects of the drug. These typically include nausea, jaw clenching and teeth grinding, muscular tension and a post-drug "crash," that may include several days of fatigue, slight depression and sleep disturbances. Although it is very rare, some people have reported extreme anxiety and stress reactions to MDMA and recent studies have found persistent sleep disturbances, anxiety and depression among some heavy users. There has been great concern about ecstasy-related deaths and, while overdose and death is possible, the annual number of deaths from ecstasy is low and is far less than the number of deaths from cocaine, heroin or drugs that are legally prescribed. Death related to the ingestion of ecstasy has been most commonly observed in a few users with previously undiagnosed heart disease and those who died from hyperthermia-related problems while taking ecstasy at a rave party. Some deaths that were initially attributed to ecstasy eventually were found to be caused by drugs that were sold as ecstasy, but contained entirely different substances such as para-methoxyamphetamine (PMA), drugs used with alcohol, or other drugs combined with ecstasy.

This points out the extreme dangers of recreational drug use and, particularly the use of drugs that are manufactured in clandestine facilities. In 1985 the Drug Enforcement Administration placed ecstasy in Schedule I, a category restricted for drugs that are believed to have no accepted medical use and a high potential for abuse. This effectively made the production of ecstasy illegal, except for a small group of researchers who are licensed to study the effects of the drug in laboratory animals, and it stopped all clinical work and research involving human subjects.

Since that time, the illegal production of ecstasy has skyrocketed and so have all of the risks associated with drugs that are manufactured illegally because the purity and dose of the pills is uncertain. Pills that are sold as ecstasy contain widely variable doses of MDMA, and some pills are adulterated with other drugs such as ketamine, methamphetamine, ephedirne, pseudophedrine, caffeine, cocaine, and dextromethorphan (DXM). Some pills contain no MDMA at all and are composed of a variety of different substances that are totally unrelated to ecstasy, some of which are dangerous and life threatening.

Another danger of recreational use of ecstasy has been linked to hyperthermia, or increased body temperature, when users at rave parties over-exert themselves while dancing in hot and crowded rooms, sweat profusely and fail to drink sufficient fluids. Unfortunately, drinking too much water while taking ecstasy appears to have led to death in at least one recent case.

One of the most important and hotly debated areas of concern has been evidence from several studies that has shown MDMA to be neurotoxic, causing long-lasting or possibly permanent damage to the neurons that release serotonin in the brain. The evidence for this comes primarily from laboratory studies in which rats and monkeys were given large and repeated doses of the drug. Some studies showed eventual recovery of the damaged brain cells, while others showed no recovery at all. Evidence of this type of potential damage in humans comes from brain imaging and spinal fluid studies of heavy users who had taken MDMA between 50-200 times. Their brains showed similar changes as the rats and monkeys and their spinal fluid showed decreased levels of the main serotonin metabolite. Despite these differences, few showed behavioral abnormalities associated with these brain changes. Although this research has been strongly critiqued by those in the professional community who advocate for controlled clinical studies of MDMA, it is probably safe to conclude that large, repeated doses of MDMA can cause damage that may be irreversible. Neurotoxicity of this sort has also been found with high doses of widely prescribed antidepressants such Prozac and Zoloft. However, scientists cannot yet predict the long-term behavioral consequences, if any, of these changes.

Additionally, some studies have shown that MDMA also may impair memory and cognitive performance. The data here are not as convincing to some researchers who note that none of the people in these studies reported any complaints related to memory impairment or cognitive dysfunction, nor did they exhibit obvious impairment to the researchers. In addition, the subjects were poly-drug users whose use of drugs other than MDMA might account for any deficiencies found.

This points to one of the overriding problems with most research related to ecstasy in the United States. Current government funding of ecstasy research is directed almost exclusively at the dangers associated with its use. MDMA proponents who are most interested in studying the clinical utility of the drug for use in psychotherapy and pain management for terminal cancer patients must turn to private funding sources such as the Multidisciplinary Association for Psychedelic Studies (MAPS), and even if funding is obtained, they then face the hurdle of gaining government approval to test the drug on human subjects. For this reason, research in this area has proceeded at a snail's pace. Consequently, research on the negative effects of the drug is much more prevalent and widely publicized in the media, while its therapeutic utility is largely untested due to these constraints.

One thing is clear - recreational ecstasy use is becoming increasingly popular among teenagers and young adults alike, and the ever-growing illegal MDMA drug trade is supplying pills of unknown quality and strength to these users. Although it is unlikely that most ecstasy users will experience the drug's most serious adverse effects, the dangers associated with recreational use of MDMA cannot be ignored. At the very least, the possible very serious consequences associated with heavy or prolonged use justify extreme concern.