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DRUG ABUSE SERIES
MDMA
Health and Welfare Agency State of California
Clifford L. Allenby, Secretary George Deukmejian, Governor
The Monograph Series which is issued by the Drug Abuse
Information and Monitoring Project is prepared for and funded by
the State of California Department of Alcohol and Drug Program
under contracts # D-0053-5 and # D-0001-7. The primary purpose
of this series is to provide information to the drug abuse
treatment community and to the general public on the epidemiology
and treatment of drug abuse.
The material herein does not necessarily reflect the opinions,
official policy, or position of the Department of Alcohol and
Drug Program of the State of California. The views of this study
are solely those of the authors.
All material in this volume except quoted passages from
copyrighted sources is in the public domain and may be used or
reproduced without permission from DAIMP or ADP or the authors.
Citation of the source is appreciated.
---
MDMA
By Jerome E. Beck
School of Public Health
Berkeley, CA
Institute for Scientific Analysis
---
PREFACE
In September 1986, the California Department of Alcohol and Drug
Programs (ADP) formally sponsored initiation of the Drug Abuse
Information and Monitoring Project (DAIMP). One of the primary
objectives of this project is to conduct ethnographic and
epidemiological research in order to provide information on the
new and changing conditions in drug abuse. Another key objective
of the project is to provide an assessment of state needs and
resources to deal with the treatment and prevention of drug
abuse. As a third objective, DAIMP will produce a series of
monographs focusing on specific issues in drug abuse that are
useful to California's drug program network.
The continuing problem of drug abuse has been recently compounded
by several developments. These include the increasing amounts of
illicit drugs (e.g., heroin and cocaine) being imported into the
U.S., by an increasing number of routes, and the appearance of
new and different drugs. The abuse potential of these newer
drugs has not yet been ascertained. California is especially
affected by these developments.
The use of drugs such as MDMA has increased since their
introduction on the street in the early 1970's. Only due to
recent mass media interest has the public become aware of these
drugs. While some therapists have portrayed the drug MDMA as a
therapeutic tool, those in the drug treatment network are
concerned about its abuse potential. Thus, there is a
polarization of opinion regarding MDMA and similar drugs. Much
of the current knowledge about MDMA is limited as it relies upon
anecdotal sources.
As part of the DAIMP series, this first monograph presents
information about MDMA. It is intended to inform the public and
those in the field who must learn about these newer drugs and
their unique effects. As part of continuing research on drug
abuse the current monograph represents an important contribution
to the understanding of a much publicized drug and its potential
for abuse.
---
FACT SHEET
WHAT IS MDMA?
MDMA (3,4-methylenedioxymethamphetamine) is the N-methyl
analog of MDA, and shares similarities to both mescaline, a
hallucinogen, and amphetamines, a family of stimulants. Although
often referred to itself as a hallucinogen, this association is
somewhat erroneous. The effects of MDMA dramatically differ from
those of LSD and other psychedelics, with a notable lack of the
perceptual distortions usually associated with these substances.
WHO IS USING MDMA?
MDMA appears to be most often used in urban areas,
particularly certain college towns (e.g. UC Berkeley, UCLA, UC
Santa Barbara, and UC Santa Cruz). In the past, some
psychotherapists have employed it, under carefully supervised
conditions, for a wide variety of purposes, ranging from
improving couple communication to dealing with rape trauma.
Illicit use has been most commonly associated with college
students, gays and "yuppies."
HOW IS MDMA MOST COMMONLY USED?
MDMA is most often ingested orally, although inhalation and
injection have been infrequently reported. The usual dose ranges
from 100 to 150 mg and costs between $10 and $20. Although
analyzed samples have been fairly pure in the past, this may
change due to increased popularity and newly illicit status.
---
WHY ARE PEOPLE USING MDMA?
Many users of MDMA are probably attracted to the drug for
the same reasons as some psychotherapists. They feel that MDMA
has the ability to increase empathy and self-insight.
Reportedly, the advantages of MDMA over traditional psychedelics
are less distortion of sensory perception and fewer unpleasant
emotional reactions. In addition, many individuals describe
strong euphoric and/or sensual effects associated with MDMA.
DESCRIBE A 'TYPICAL' MDMA EXPERIENCE
Effects generally appear within 20-60 minutes, when the user
often experiences a brief "rush" of energy, usually described as
mild but euphoric. After this rush, the high levels off to a
plateau which lasts 2-3 hours and is followed by a gradual
"coming down" sensation, culminating in a feeling of fatigue.
MDMA exerts amphetamine-like effects which include dilated
pupils, dry mouth and throat, tension in the lower jaw, grinding
of the teeth, and overall stimulation. These side effects are
dose dependent and will vary depending on the health of the
individual user. In addition, MDMA exerts a strong paradoxical
effect of relaxation which often causes many users to be unaware
of the stimulant side effects. Most users cite a dramatic drop
in defense mechanisms and increased empathy towards others.
Combined with the stimulant effect, this generally produces an
increase in intimate communication.
---
WHAT IS KNOWN ABOUT THE TOXICITY OF MDMA?
Unfortunately, very little. So far, MDMA has been
associated with few overdoses or deaths. However, studies in
rats have indicated that large intravenous doses of MDMA in rats
are associated with suspected degeneration of serotonergic nerve
terminals in certain areas of the brain. Also, there may be some
suppression of the immune system. Further research is needed to
determine the significance of this damage, and to what extent it
may occur in humans.
WHAT IS MDMA'S ABUSE POTENTIAL?
The euphoric effects of MDMA, combined with its street
reputation, would suggest a significant abuse potential. To
date, however, there appear to be relatively few cases of what
might be considered serious abuse of MDMA. Excessive use is
probably self limiting in that the frequent use of MDMA almost
invariably produces a strong dysphoric (unpleasant) reaction,
that is only exacerbated with continued use. In addition,
frequent use produces an almost total loss of the desired actions
with a greater rapidity and intensity than with other more
commonly abused substances.
---
EXECUTIVE SUMMARY
The 1980's have witnessed the emergence and popularization
of a rather unique psychoactive substance -- MDMA, (3,4-
methylenedioxy-methamphetamine), also known as "Adam," "Ecstasy,"
or "XTC". Extensive media coverage recently highlighted what
appears to be a dramatic increase in both therapeutic and
recreational use. A controversy has since ensued providing very
different perspectives on the substance. Some psychotherapists
view MDMA as a therapeutic aid which, when combined with
psychological treatment, has benefits that outweigh potential
health consequences and see minimal harm associated with
carefully monitored use. Some drug treatment counselors and drug
enforcement officials, on the other hand, see it as a potentially
dangerous substance possessing harmful actions, and increasingly
being abused outside of therapeutic circumstances.
Unfortunately, research has only just begun to address many of
the questions and concerns that have arisen. Consequently, it
can be anticipated that much of the following information will
become dated as more formal studies are completed.
Research examining patterns of MDMA use has been minimal.
Most of the information available regarding street use of MDMA is
based on anecdotal accounts given to the media, therapists and
substance abuse professionals. Beck has conducted preliminary
research over the last ten years interviewing hundreds of
individuals in the San Francisco Bay Area and at the University
of Oregon in Eugene. Zinberg (1976) has published the only
naturalistic study of 23 users of MDA. Greer (1983) administered
MDMA to 29 subjects in a therapeutic setting. Downing (1985)
studied the effects of a single exposure to MDMA among 21
individuals. Siegel (1985) and Seymour (1986) have ongoing
studies at UCLA and the Haight Ashbury Free Clinic, respectively.
Much of the information for this paper is based upon these
studies, testimony at federal hearings, and personal
communications.
MDMA, which is essentially the successor to MDA, first
appeared on the street in the early 1970's. Use remained very
limited until the end of the decade. On July 1, 1985 the Drug
Enforcement Administration (DEA) used its emergency scheduling
power to temporarily place MDMA in Schedule I of the Controlled
Substances Act. The DEA's actions were challenged by some
therapists and researchers who argued that a Schedule I status
would severely hinder research into what they regarded as MDMA's
therapeutic potential. Based on testimony from federal hearings,
the administrative law judge recommended that MDMA be placed in
Schedule III -- a category for drugs with accepted medical use
and only a low to moderate abuse potential. However, the DEA
administrator rejected his recommendation and MDMA was
permanently placed in Schedule I effective November 13, 1986.
The scheduling process and ensuing reaction by therapists using
the drug in their practices brought MDMA to national attention
via mass media features which often sensationalized the reputed
euphoric and therapeutic qualities of MDMA. The increase in
publicity was accompanied by an escalation in street demand from
an estimated 10,000 doses distributed in all of 1976 to 30,000
doses distributed per month in 1985 (Siegel, 1986). The DEA
found evidence of use in a majority of states.
MDMA appears to be most often used in urban areas,
particularly certain college towns. Its use has been most
commonly associated with college students, gays and "yuppies".
The usual dose ranges from 100 to 150 mg. and costs between $10
and $20. MDMA is most often ingested orally, although inhalation
and injection have also been infrequently reported. Drug effects
generally appear within 20-60 minutes after ingestion, when the
user often experiences a brief "rush" of energy, usually
described as mild but euphoric. After this rush, the high levels
off to a plateau which lasts 2-3 hours and is followed by a
gradual "coming down" sensation, culminating in a feeling of
fatigue.
MDMA exerts amphetamine-like side effects on the body,
including dilated pupils, dry mouth and throat, tension in the
lower jaw, grinding of the teeth, and overall stimulation. These
effects vary depending on dose. In addition, MDMA exerts a
strong paradoxical effect of relaxation, which often causes many
users to be unaware of the stimulant side effects. Most users
cite a dramatic drop in defense mechanisms and increased empathy
towards others. Combined with the stimulant effect, this
generally produces an increase in intimate communication.
---
Psychotherapeutic Effects
It appears that well over one hundred psychiatrists and
other therapists have employed MDMA as a therapeutic adjunct. At
the federal hearings several psychiatrists praised MDMA's ability
to increase both empathy and self-insight. They felt that a
major advantage of MDMA over the traditional psychedelics was
that it produced far less distortion of sensory perception and
fewer unpleasant emotional reactions. Although some preliminary
research suggested that MDMA has significant therapeutic
potential, the notable absence of well-controlled, double-blind
studies seriously limits any conclusions concerning the possible
efficacy or risk associated with the use of MDMA in therapy.
Health Risks
Although some research has assessed toxic and lethal doses
in animals, little is known about MDMA's potential toxicity for
humans. A few deaths have been associated with the use of MDMA,
but its role as a causative factor in each case remains
uncertain. As of April, 1986 20 emergency room incidents for
MDMA had been listed in the federal government's Drug Abuse
Warning Network (DAWN). Ignorance of the substance undoubtedly
contributes to underreporting. However, the number of mentions
still appears to be rather low when compared with the suspected
extent of use described by Siegel and the DEA.
MDMA has been associated with relatively few overdoses or
deaths. However, it's neurotoxic potential is cause for concern.
Acute and chronic problems are most often associated with the
repeated use of high dosages. Generally, the side effects of
MDMA are similar to those of amphetamine. MDMA also appears to
exert an adverse action on the immunological response of some
individuals, particularly with heavy use. Long-term users often
describe increasingly uncomfortable and prolonged "burn-out"
periods, sometimes lasting two or more days. Many individuals
have also reported an increased susceptibility to various
ailments, particularly sore throats, colds, flus, and herpes
outbreaks. It should be noted that these reactions appear to be
rare in novice users and individuals in good physical and mental
health.
Based on the limited information available, researchers have
identified the following medical conditions as possible
contraindications to MDMA use: diabetes, diminished liver
function, epilepsy, glaucoma, heart disease, hypertension,
hypoglycemia, hyperthyroidism and pregnancy.
Infrequent psychological problems have been associated with
the use of MDMA. Rare episodes of hyperventilation have been
noted, but this phase is transitory. In addition, problems occur
for some individuals who, in attempts at self-therapy, run the
risk of exacerbating their emotional problems with unsupervised
episodes.
Among individuals who have tried both MDMA and cocaine, Beck
found that the majority usually express a strong preference for
MDMA which would suggest a high abuse potential. However, in
sharp contrast to cocaine, there appear to be relatively few
cases of what might be considered serious abuse of MDMA.
Excessive use is probably self limiting in that frequent use of
MDMA always produces a strong dysphoric (unpleasant) reaction,
that is only increased with continued use. In addition, frequent
use produces an almost total loss of the desired actions with a
greater rapidity and intensity than with other more commonly
abused substances.
Conclusion
Media accounts and substance abuse professionals often
dismiss MDMA as a short-term fad. However, the perceived
therapeutic and/or euphoric effects combined with the ease with
which MDMA is usually experienced can be expected to attract new
users. The danger in this regard is the uncertain potential for
abuse. In addition, there are potentially severe health risks
associated with MDMA and probable contraindications. This is
particularly true with repeated use of high dosages which may
lead to acute or chronic medical and psychological problems.
Unfortunately, our current knowledge regarding nearly every
aspect of MDMA is extremely limited and based almost exclusively
on anecdotal data. Research is obviously needed to better
determine the potential risks of a substance which is rapidly
establishing itself in our drug culture.
---
I. INTRODUCTION
The last decade witnessed the emergence and popularization
of the "drug of the 80's"--MDMA. Also known as "Adam,"
"Ecstasy," or "XTC," extensive media coverage recently
highlighted what appears to be a dramatic increase in both
therapeutic and recreational use. A controversy has since ensued
providing very different perspectives on the substance. Some
psychotherapists view MDMA as a therapeutic aid, which, when
combined with psychological treatment, has benefits that outweigh
potential health consequences and see minimal harm associated
with carefully monitored use (Greer, 1985, Grinspoon, 1985,
Lynch, 1985, Wolfson, 1985). Some drug treatment counselors and
drug enforcement officials, on the other hand, see it as a
potentially dangerous substance possessing harmful actions, and
increasingly being abused outside the therapeutic community
(United States Department of Justice, 1985, Sapienza, 1985,
Sapienza, 1986). As pharmacologist Alexander Shulgin describes
it:
MDMA has been thrust upon the public awareness as a
largely unknown drug which to some is a medical miracle
and to others a social devil. ... There have been the
born-again protagonists who say that once you have tried
it you will see the light and will defend it against any
attack, and there have been the staunch antagonists who
say this is nothing but LSD revisited and it will
certainly destroy our youth. There are many voices to
be heard presenting the modest inventory of facts that
are known, but there is no one who will answer questions
in a way that can be heard by both camps. (1985, p. 3)
While no formal survey has been conducted to determine the
exact extent of MDMA use, nonmedical use appears to be
increasing. Still, MDMA remains largely unknown to much of
American society, including frequent users of other psychoactive
drugs. There are signs, however, that this is changing.
Research has only just begun to address many of the questions and
concerns that have arisen. Consequently, it can be anticipated
that much of the following information will become dated as more
formal studies are completed.1
The uniqueness of MDMA (3,4-methylenedioxymethamphetamine)
can be seen in the controversy over the proper terminology used
to describe it (Beck, 1986, Seymour, 1986). As the N-methyl
analogue of MDA, it is related to both mescaline and the
amphetamines. Although often referred to as a hallucinogen, this
association is somewhat erroneous. The effects of MDMA
dramatically differ from those of LSD and other psychedelics,
with a notable lack of the perceptual distortions usually
associated with these substances.
The label, "designer drugs" has often been applied to MDMA.
Designer drugs have been described as "substances wherein the
psychoactive properties of a scheduled drug have been retained,
but the molecular structure has been altered in order to avoid
prosecution under the Controlled Substances Act" (Smith and
Seymour, 1985: 1). Whether MDMA is actually a designer drug is
debatable since it was first synthesized and patented in 1914
long before the Controlled Substances Act (1970) came into being.
Nevertheless, the media has occasionally confused MDMA with the
other designer drugs (Beck and Morgan, 1986; Seymour, 1986).
Most often these substances are synthetic opiates employed as
heroin substitutes and which, because of their potency, are
considerably more dangerous. Among these are MPTP (capable of
causing Parkinson's disease) and the fentanyl analogues
(responsible for a large number of fatal overdoses).2 Therefore,
it is important for substance abuse professionals to be extremely
cautious in learning about the different designer drugs and the
unique effects of each.
---
II. ORIGINS AND DISTRIBUTION
In terms of popular use, MDMA is essentially the successor
to MDA, the counterculture "love drug" of the late 1960s and
early 1970s. MDA first appeared on the streets in 1967 and
became known as a drug which produced a sensual, easily managed
psychedelic high (Meyers, Rose, & Smith, 1967/68). After MDA was
placed in Schedule I of the Controlled Substances Act in 1970,
its use seemed to level off and gradually decline. While MDMA
first appeared on the street in the early 1970s, use remained
very limited until the end of the decade. MDMA was a legal
substance until July 1985 when the Drug Enforcement
Administration (DEA) used its emergency scheduling power to
temporarily place MDMA in Schedule I of the Controlled Substances
Act (Federal Register, May 31, 1985). This schedule is reserved
for those drugs designated as possessing no medical use and
having a high potential for abuse (e.g., heroin, LSD). The DEA's
actions were challenged by some therapists and researchers who
argued that a Schedule I status would severely hinder research
into what they regarded as MDMA's therapeutic potential.
According to most reports (Beck, 1986, Seymour, 1986),
psychotherapists who had been using the drug as part of
therapeutic programs since the mid- to late 1970s found its
benefits to outweigh any potential health risks for patients
under their care.
In response to these challenges, three federal
administrative hearings were held to help determine the final
scheduling of MDMA. Based on testimony from the hearings, the
administrative law judge concurred with the proponent therapists
in recommending that MDMA be placed in Schedule III -- a category
for drugs with accepted medical use and only a low to moderate
abuse potential (Young, 1986). However, the DEA administrator
rejected this recommendation and MDMA was permanently placed in
Schedule I effective November 13, 1986 (Federal Register, October
14, 1986).
The scheduling process and ensuing reaction by therapists
soon brought MDMA to national attention. Nearly all the major
newspapers and magazines devoted features to the substance,
sensationalizing the reputed euphoric and therapeutic qualities
of MDMA (Life, 1985, Newsweek, 1985, Time, 1985). The increase
in publicity was accompanied by an increased street demand.
University of California, Los Angeles (UCLA) psychopharmacologist
Ronald Siegel (1985:2) stated that street use "escalated from an
estimated 10,000 doses distributed in all of 1976 to 30,000 doses
distributed per month in 1985." The DEA found evidence of use in
a majority of states and estimated that "30,000 dosage units are
distributed each month in one Texas city" (1985:2). These
estimates (made just before MDMA became illegal) must be
considered highly speculative and it is unknown what changes in
use have occurred since then.
---
III. EPIDEMIOLOGY
Although research examining recreational use patterns of
MDMA has been minimal, the drug appears to be most popular in
urban areas, especially college towns (Beck, 1986, Renfroe,
1986).4 Many users belong to groups who have traditionally been
associated with MDA use. Prominent among these are gays and
college students. Newsweek noted that MDMA "has become popular
over the last two years on college campuses, where it is
considered an aphrodisiac" (Newsweek, 1985, p.96). This
reputation explains why MDMA seems to be increasing in popularity
even among groups such as college fraternities, which are not
traditional psychedelic users (Beck, 1986).
One of the first media accounts of MDMA described it as a
"yuppie psychedelic" whose popularity was spreading rapidly among
educated professionals in their 30s and 40s. The article stated
that "in contrast to the mind-bending hallucinogens of the '60s,
Adam is reported to leave one's faculties fairly clear," (Mandel,
1984, p.A2). The same article quoted a drug abuse program
director as noting that "some of these people haven't touched a
psychedelic for 10 or 15 years, but cocaine is really scaring
folks these days. They are turning elsewhere" (Mandel, 1984,
p.A2). Many individuals describe using MDMA on occasion while
claiming to rarely or never use other more commonly available
illegal drugs or even alcohol (Beck, 1986, Seymour, 1986). As
the author of a recent article titled "Drugless in L.A." stated,
"For veterans of the '60s it is interesting to note that the
major new drug of the '80s, Ecstasy, has been hyped as a drug
that is not really a drug" (Kaye, 1986, p.34).
MDMA's cost has ranged from $50 to $120 a gram, yielding 5
to 15 doses per gram. The price has increased slowly since MDMA
became illegal. The oral route is by far the most common method
of ingestion, although some individuals occasionally inhale the
drug. Intravenous (IV) use seems to be rare. At times a small
quantity of MDMA will be swallowed or inhaled as a "booster"
after the initial oral dose begins to wear off. A continuous use
of boosters, however, generally leads to great fatigue the next
day.
Although MDMA has been described occasionally as a "party
drug," that is not its most common use pattern. Most individuals
describe taking it with a small intimate group or another person,
usually a close friend, spouse, or lover. A major exception was
certain bars in the Dallas, Texas, area, where tablets were
purchased at the door or counter, and where, according to the
DEA, 30,000 dosage units of MDMA a month were sold by one local
dealer alone, right up until the scheduling ban (United States
Department of Justice, 1985).
---
IV. PSYCHOPHARMACOLOGY
A. Effects
The MDMA dosage range between effectiveness and toxicity is
fairly narrow. It is reported that toxic effects begin to
increase sharply over the 200 mg dose level. Effects generally
appear within 20 to 60 minutes, when the user experiences a
"rush" usually described as mild but euphoric. The "rush" may
last from a few minutes to half an hour or not occur at all,
depending on the user's mental set and the environment, the dose
ingested, and the MDMA's quality. Zinberg (1976) described a
similar pattern with MDA in an early field study. After the
rush, the high levels off to a plateau, usually lasting from two
to three hours, followed by a gradual "coming down" sensation,
ending with a feeling of fatigue. Insomnia, however, may persist
long after the fatigue stage, depending on the dosage and the
user.
MDMA, although milder and shorter-lasting than MDA, still
exerts amphetamine-like effects on the body, including dilated
pupils, dry mouth and throat, tension in the lower jaw, grinding
of the teeth, and overall stimulation. These effects vary
depending on dose. In addition, MDMA exerts a strong paradoxical
effect of relaxation, which often causes many users to be unaware
of the stimulant side effects (Beck, 1986). Most users cite a
dramatic drop in defense mechanisms and increased empathy towards
others. Combined with the stimulant effect, this generally
produces an increase in intimate communication. Although both
MDA and MDMA have been labeled "aphrodisiacs," users most often
describe a more sensual, rather than sexual, experience.
B. Psychotherapeutic Effects
Research evaluating MDA as a psychotherapeutic tool preceded
that of MDMA. Studies were conducted by Naranjo et al. (1967),
Naranjo (1973), Turek et al. (1974), and Yensen et al. (1976).
The studies described similar outcomes and unanimously supported
the therapeutic potential of MDA. Subjects described an
intensification of feelings, facilitation of self-insight, and
heightened empathy as qualitative characteristics of MDA.
Zinberg (1976) carried out what is still the only published
field study of either MDA or MDMA. He interviewed 23 experienced
MDA users while they were high in their "natural" settings,
either individually or in groups. None of the users reported any
past negative experiences. Zinberg observed no panic reactions
or hallucinatory episodes.
The most complete study of MDMA's effects published to date
was conducted by Greer (1983) who administered the drug to 29
subjects (none with severe mental disorders) in a therapeutic
setting. Most of the subjects were given an oral dose of 75-150
mg of MDMA. After about two hours, they were offered a second
dose of 50-75 mg. Greer reported that all the subjects
experienced some benefits. Each described feeling closer and
more intimate with the others present, and almost all reported
positive changes in their feelings and attitudes. Moreover, 17
subjects reported some cognitive benefit (e.g., an expanded
mental perspective and insight into personal patterns or
problems). Follow-up questionnaires were given at a median time
of about nine months after the last session, and the majority of
subjects reported positive changes in work, relationships, mood,
and attitude. Half reported decreased use of mood-altering
drugs, often mentioning that these substances seemed less
appealing after experiencing MDMA. According to Greer, "The
ability not only to feel free of conflict--which can be provided
by many drugs of abuse--but to learn how to prevent conflicts in
everyday life seems unique to MDMA as a therapeutic adjunct"
(Greer, 1983, p.12).
It appears that well over one hundred psychiatrists and
other therapists have employed MDMA as a therapeutic adjunct.
Several psychiatrists testified on behalf of MDMA at the federal
administrative hearings concerning permanent scheduling. Wolfson
(1985) cited optimistic results in the treatment of a few
psychotic patients. He concluded that "MDMA provides a positive
alternative to the dark and negative experiences of people
experiencing psychotic states" (p.9). In general, therapists
attending the hearings believed that a major advantage of MDMA
(less so with MDA) over the traditional psychedelics is that it
produces far less distortion of sensory perception and fewer
unpleasant emotional reactions. The experience is generally seen
as both personal and familiar and seems to differ only in its
degree of intensity from that of everyday experience. This is in
sharp contrast to the effects of most other psychedelics, where
the experience is often perceived as unfamiliar and
transpersonal. As Grinspoon asserted, "MDMA appears to have some
of the advantages of LSD-like drugs without most of the
corresponding disadvantages" (Grinspoon, 1985, p.3).
Although some preliminary research suggested that MDMA has
significant therapeutic potential, the notable absence of well-
controlled, double-blind studies limits conclusions about the
possible efficacy or risks associated with the use of MDMA in
therapy. As Siegel recently noted, "MDMA has been promoted as a
cure for everything from personal depression to alienation to
cocaine addiction. . . . It's got a lot of notoriety, but the
clinical claims made for its efficacy are totally unsupported at
this time" (Siegel, 1985, p.14). Researchers and therapists are
aware that only formal, well-controlled research will adequately
assess the true therapeutic value of MDMA.
---
V. RELATED PROBLEMS/HEALTH RISKS
A. Physiological Problems.
Although little is known about the potential toxicity for
humans of MDA, MDMA, or any of the other amphetamine
psychedelics, some research has assessed toxic and lethal doses
in animals (Hardman, Haavik, & Seevers, 1973, Davis, & Borne,
1984). Assuming the results of the data on animals can be
generalized to humans, indications are that a lethal IV dose for
50% (LD-50) of 150-pound individuals would be about 1100 to 1780
mg. The dangers of such extrapolation are well known, but these
figures would seem to indicate that a lethal dose for injected
MDMA may be a little over 10 times the usual 100-150 mg amount.
A recent study suggested a much higher LD-50 for MDMA when
ingested orally. The single-dose oral LD-50 for rats was found
to be approximately 325 mg/kg, with death associated with kidney
and liver damage (Goad 1985). This dose corresponds to over 150
times the human therapeutic level (1.5-2.0 mg/kg).
Street use of MDA has been connected to a number of deaths,
although not clearly, because other drugs were also involved
(Reed, Cravey, & Sedgwick, 1972). Some deaths reported in 1972
and 1973 to be a result of MDA toxicity are now known to have
occurred as a result of ingesting another amphetamine derivative:
PMA (paramethoxyamphetamine) (Inaba, Way, & Blum, 1978). The PMA
compound, frequently passed off as MDA, often caused a dangerous
rise in blood pressure at effective doses. Fortunately, PMA
appears to have been totally withdrawn from circulation
(Stafford, 1983).
A few deaths have been associated with the use of MDMA, but
its role as a causative factor in these deaths remains uncertain
(Shulgin, 1985). As of April, 1986, 20 emergency room incidents
for MDMA had been listed in the federal government's Drug Abuse
Warning Network (DAWN) (Newmeyer, 1986). Ignorance of the
substance undoubtedly contributes to underreporting. However, the
number of mentions still appears to be rather low when compared
with the suspected extent of use described by Siegel (1985) and
the DEA (Sapienza, 1985).
While associated with relatively few overdoses or deaths,
MDMA's neurotoxic potential is cause for concern. Studies in
rats conducted at the University of Chicago indicate that large
intravenous doses of MDA and MDMA in rats are associated with
suspected degeneration of serotonergic ("chemical messenger")
nerve terminals in certain areas of the brain (Ricaurte, 1986,
Ricaurte, Bryan, Strauss, Seiden, & Schuster, 1985). Also, there
may be some suppression of the immune system. Serotonin is a
neurotransmitter that apparently plays an important role in
regulating sleep, mood, sexual activity, and sensitivity to
stimuli (Schuster, 1986). However, the University of Chicago
researchers acknowledged that "because of the differences in
species, dose, frequency, and route of administration, as well as
differences in the way in which rats and humans metabolize
amphetamine, it would be premature to extrapolate our findings to
humans" (Ricaurte, et al., 1985, p.988). In addition, our
overall lack of knowledge concerning serotonin makes it difficult
to interpret the significance of these findings. Research is now
being conducted at Stanford and other institutions to determine
the potential significance of this damage, whether it occurs in
humans, and if so, at what dosage level (both orally and
intravenously).
A number of acute and chronic problems have been identified.
for example, MDMA may exert an adverse action on the
immunological response of some individuals. This effect is most
often associated with repeated high dosages, particularly in
individuals who have used the drug over a long period of time.
Long-term users often describe increasingly uncomfortable and
prolonged "burn-out" periods, sometimes lasting two or more days.
Many individuals have also reported an increased susceptibility
to various ailments, particularly sore throats, colds, flus, and
herpes outbreaks (Beck, 1986). These reactions appear to be rare
in novice users and individuals in good physical and mental
health.
Generally, many of the side effects of MDMA are similar to
those of amphetamine and, as Weil (1976) noted with MDA, are very
much dose-related. One of the most common annoying effects is a
tension of the jaw muscles, often progressing to involuntary
grinding of the teeth, an effect noted with MDMA and amphetamine-
like drugs in general. Nausea and dizziness are occasionally
reported, most often during the initial onset of the high.
Individuals become dehydrated and should be drinking water or
juice throughout the experience. Unfortunately, some choose to
drink alcoholic beverages, which increase dehydration. As with
other stimulants, individuals under the influence of MDMA are
often capable of ingesting large quantities of alcohol with few
discernible effects until a short time later. Thus, overdose of
alcohol likely plays a significant role in the next day's
hangover (Beck, 1986). The potentially toxic interaction between
MDMA and alcohol merits further investigation.
One research project studied the effects of a single
exposure to MDMA among 21 healthy individuals. All these
subjects had used MDMA on previous occasions. Using blood
chemistry, physiological measures, and neurological examinations,
the researchers concluded that:
This experimental situation produced no observed
or reported psychological or physiological
damage, either during the twenty-four hour study
period, or during the three month follow-up
period. From the information presented here one
can say only that MDMA, at the doses tested, has
remarkably consistent and predictable
physiological effects which are transient and
free of clinically apparent major toxicity
(Downing, 1985, p.5-6).
The research design of this experiment was heavily
criticized by an FDA pharmacologist at the administrative
hearings (Tocus, 1985). He agreed with the study's conclusion
that "there is insufficient evidence to judge accurately either
harm or benefit" (Downing, 1985, p.6).
Based on the limited information available, researchers have
identified the following medical conditions as possible
contraindications to MDMA use: diabetes, diminished liver
function, epilepsy, glaucoma, heart disease, hypertension,
hypoglycemia, hyperthyroidism and pregnancy (Beck, 1986, Seymour,
1986; Greer, 1983).
B. Psychological Problems.
The most frequent use of MDMA usually occurs during the
first months following the initial experience. After first
exposure, some individuals will attempt to continually
reexperience the positive aspects of the drug. However, this
abusive cycle tends to be brief. Within a short time, the
frequent use of MDMA almost invariably produces a strong
dysphoric reaction, which is only exacerbated with continued use.
The increasing number of unpleasant side effects coupled with an
almost total loss of desired effects occurs with greater rapidity
and intensity than they do with other more commonly abused
substances (Beck, 1986; Seymour, 1986; Greer, 1983; Strassman,
1985). However, since the popularity of MDMA is fairly recent,
more time is needed to see how use patterns develop among new
user groups introduced to the drug (e.g., adolescents, i.v.
users).
The strong euphoria associated with MDMA points towards a
high abuse potential. Although Seymour (1986) states that MDMA
doesn't seem to pack a "euphoric punch" or "rush" comparable to
other drugs, Beck (1986) finds just the opposite to be true.
Among individuals who have tried both MDMA and cocaine, the
majority usually express a strong preference for the longer,
smoother euphoria provided by MDMA. As one individual
interviewed by the NIDA-funded Cocaine Cessation Project
described it:
Cocaine usually gives me an up-and-down jagged
feeling that lasts for only a short time. I
alternately like it and hate it, though for some
reason it has very seductive qualities.
"Ecstasy," on the other hand, is just as the name
implies. It's "state of the art." It puts me in
a place of total bliss for 3 or 4 hours. Whereas
coke often makes me feel jittery, MDMA is very
smooth. I know it has amphetamine in it, but I
feel so relaxed . . . (Murphy, 1986).
Recent studies at Johns Hopkins found that primates will
self-administer MDMA at regular intervals (although not quite as
frequently as cocaine) (Sapienza, 1986). In sharp contrast to
cocaine, however, there appear to be relatively few cases of what
might be considered heavy abuse of MDMA (Beck, 1986; Seymour,
1986; Siegel, 1985; Greer, 1983). In an ongoing study of MDMA
users, Siegel (1985) cited that the most common patterns of use
are "experimental" (ten times or less in lifetime) or "social-
recreational" (one to four times per month). He also said that
"compulsive patterns marked by escalating dose and frequency of
use have not been reported with MDMA users" (Siegel, 1985, p.2-3).
Occasional psychological problems have been reported with
MDMA use, but appear to be quite rare. Episodes of
hyperventilation have been noted (Beck, 1986; Seymour, 1986;
Siegel, 1985), but these almost always occur during the onset of
the experience as part of a generalized panic reaction.
Reassurance that the phase is transitory generally lessens this
problem.
In 1985, the Haight Ashbury Free Medical Clinic reported
that each month three to four individuals sought treatment for
problems related to MDA, MDMA, or related drugs (Seymour, 1986).
Some clients present acute symptoms that include anxiety, rapid
pulse, and in advanced cases, paranoia. As Seymour notes: "With
MDMA and the methoxylated amphetamines, as is the case with most
stimulants and psychedelics, the acute toxicity symptoms that are
usually seen in treatment are similar and result from taking too
much of the drug. These dose related symptoms usually dissipate
as the drug wears off, and the patient can be discharged within a
few hours" (1986: 54-55). Seymour also goes on to state that
"More severe reactions to what users believed to be MDMA have
been reported, including prolonged psychotic reactions, but we
haven't seen them" (1986: 55). Treatment is usually symptomatic
and of relatively short duration. From the Haight Ashbury data,
it appears that the highly unpleasant aftereffects associated
with heavy use of MDMA serve to temper the appetite of all but a
few users.
Some additional psychological problems have recently been
noted in an ongoing study conducted by Mim Landry of the Haight
Ashbury Training and Education Project. A "delayed anxiety
disorder" has been observed in a few individuals. This problem
typically occurs among novice users of MDMA, and the
manifestations "range from a mild anxiety or concentration
difficulties to a full-blown disorder such as a panic attack with
hyperventilation and tachycardia, phobic disorders, parathesias,
or other anxiety states" (Seymour, 1986, p.56). These initial
findings underscore a growing danger of unsuccessful attempts at
"self-therapy" by individuals who run the risk of exacerbating
their emotional problems with unsupervised episodes. Up to this
point, the Haight Ashbury research provides some of the only
significant data on the potential problems associated with MDMA
abuse.
---
VI. CONCLUSION
Media accounts and substance abuse professionals often
dismiss MDMA as a short-term fad. However, the perceived
therapeutic and/or euphoric effects combined with the ease with
which MDMA is usually experienced can be expected to attract new
users. A danger in this regard is the uncertain potential for
abuse. In addition, there are potentially severe health risks
associated with MDMA and probable contraindications. This is
particularly true with repeated use of high dosages which may
lead to acute or chronic medical and psychological problems.
Unfortunately, our current knowledge regarding nearly every
aspect of MDMA is extremely limited and based almost exclusively
on anecdotal data. Research is obviously needed to better
determine the potential risks of a substance which is rapidly
establishing itself in our drug culture.
---
VII. RESOURCES
Dr. Jerome E. Beck
Institute for Scientific Analysis
2410 Lombard St.
San Francisco, CA 94123
(415) 921-4987
Dr. Mim Landry
Haight-Ashbury Free Medical Clinics
529 Clayton Street
San Francisco, CA 94117
Dr. John Newmeyer
Haight-Ashbury Free Medical Clinics
529 Clayton Street
San Francisco, CA 94117
(415) 864-6090
Dr. George Ricuarte
Department of Neurology
Stanford University Medical Center
Palo Alto, CA 94305
Dr. Frank Sapienza
Drug Enforcement Administration
1405 Eye Streeet, NW
Washington, D.C. 20537
Dr. Richard Seymour
Haight-Ashbury Free Medical Clinics
529 Clayton Street
San Francisco, CA 94117
---
REFERENCES
Beck, J. The Popularization and Resultant Implications of a
Recently Controlled Psychoactive Substance. Contemporary Drug
Problems, 13: 1, 1986.
Beck, J. & P. Morgan. Designer Drug Confusion: A Focus on MDMA.
Journal of Drug Education, 16(3): 267-282, 1986.
Davis W. M., & R. F. Borne. Pharmacologic Investigation of
Compounds Related to 3,4-Methylenedioxyamphetamine (MDA).
Substance and Alcohol Actions/Misuse, 5: 105-110, 1984.
Downing, J. J. MDMA Pilot Study: Physiological, Psychological,
and Sociological Summary, Unpublished manuscript, 1985.
Federal Register, May 31, 1985: 50:106.
Federal Register, Oct. 14, 1986: 51:198 36552-36560.
Greer, G. MDMA: A New Psychotropic Compound and Its Effects in
Humans, Self-published (333 Rosario Hill, Sante Fe, New Mexico
87501), 1983.
Greer, G. Written Testimony Submitted on Behalf of Drs.
Grinspoon and G