Ecstasy

Synonyms: E, XTC, X, MDMA, Love Doves

• Ecstasy is an illegal 'recreational' drug containing mainly 3,4-methylenedioxy-N-methylamfetamine (MDMA)
• It remains a Class A drug which means it is against the law to use it or supply it and it cannot be prescribed by doctors.¹ A report by the Advisory Council on the Misuse of Drugs (ACMD) in February 2008 advocated its downgrading to Class B but this was rejected by the Government.^2,3
• Other substances - some more dangerous than others - have been found contaminating tablets, including the amfetamine variants methyl diethanolamine (MDEA) and methylenedioxiamfetamine (MDA), lysergic acid diethylamide (LSD), ketamine, caffeine and aspirin.⁴ The average content of MDMA in one ecstasy tablet has reduced over the past decade from around 100 mg per tablet to about 40 mg, which may explain the fact that the average number of tablets used per user over this period has increased.³
• The price of an 'ecstasy' tablet has fallen over recent years and currently can cost as little as £2.30, most commonly sold in batches of 3-5 for £10.³
• The appearance varies considerably from brown, white or pink tablets to yellow, clear, red and black, or red and yellow capsules.
• Logos, pictures or designs are found on some preparations.
• MDMA powder or crystal costs about £35-£40 per gram and is swallowed, sometimes by dabbing a moistened finger into the packet containing the powder, or less often wrapped in a piece of cigarette paper and swallowed. It is rarely injected.³

• Ecstasy was first made by two German chemists in 1912 and patented in 1914 in case some medical use could be found for it.
• The American military experimented with it in the 1950s and it was later employed by Swiss and American psychiatrists.
• As with other amfetamine-related drugs, it was already banned by the time it arrived in the UK in the 1980s but its use nevertheless became widespread due to its stimulant and mood-altering properties. It was particularly associated with the House music and warehouse rave culture scene.

• A Home Office survey suggests a peak in ecstasy use in 2001, after which it has remained stable.
• 2% of people surveyed between the ages of 16-59 admitted to using it (614,000 in 2003) and it is the most commonly used drug after cannabis among 16-24 year olds.
• There is considerable geographic variation, the highest use being in affluent urban areas
• In 2008 the Association of Chief Police Officers (ACPO) estimated that between 2.5 and 5 million MDMA tablets were taken every month in the UK.

• Ecstasy has stimulant and mild hallucinogenic properties and its effects have been described as taking a mixture of amfetamine and LSD.
• Onset takes between 20-60 minutes or longer and the effects can last for several hours.
• Many users have reported an initial 'rushing' feeling, followed by a feeling of energy, lack of aggression, empathy with others, a greater appreciation of music and increased sexual and sensual experience. It is this combination of effects plus the drug's ability to fight tiredness that have led to its popularity on the club and dance scene.

Data provided by St Thomas' and Newcastle hospitals suggest by extrapolation that there are several thousand ecstasy-related hospital admissions per year. However, it is thought that many of these are caused by ecstasy taken in combination with other drugs and the number of admissions pales in comparison to those which are alcohol-related.³ The evidence-base highlighting the adverse effects and risks of ecstasy has been criticised as studies often involve small numbers of patients.⁷ That said, the following effects have been reported:

• Immediate adverse psychological effects are more likely if the user is already anxious or takes a high dose.
• Symptoms include anxiety, panic, confusion and unpleasant distortion of the senses. These effects can last for days or even weeks.
• Organic symptoms include tightening of the jaw, nausea, sweating, loss of appetite and dry throat and mouth.
• Objective physiological signs include dilation of the pupils, hypertension and tachycardia.
• The immediate post-drug period is often characterised by extreme tiredness and users may require a long period of sleep, which may last several days (the 'comedown').
• Physical dependence is not know but psychological dependence can occur.
• A considerable body of evidence is building to suggest that ecstasy has neurotoxic properties. This has certainly been demonstrated in animal studies up to primate level. Research has suggested that consistent high-dose use leads to loss of presynaptic neurones, affecting the regulation of impulsivity and impairing decision making.⁸ One study, however, has failed to show any long-term damage to the serotonin neurones.⁹
• A case of persistent and severe psychosis following one episode of ecstasy ingestion has been reported.¹⁰ However, the studies reviewed by the ACMD suggest that ecstasy use does not appear significantly to affect the long-term mental health of the average user.³
• Ecstasy causes release of the neurotransmitter serotonin and inhibition of its re-uptake. This can in itself lead to serotonin syndrome. It is more likely to do so if taken with other drugs that increase serotonin levels. These include some antidepressants (serotonin reuptake inhibitors, serotonin/norepinephrine reuptake inhibitors, tricyclic antidepressants, mono-amine oxidase inhibitors), tramadol, certain opioids (including dextromethorpan and pethidine), and other drugs of abuse (cocaine, amfetamines and LSD).
• Impairment of long- and short-term memory may also be a feature or prolonged use.^11,12 Prospective memory (the memory of future intentions) may also be affected and this may persist long after usage has ceased.¹³
• One study reported a link to low academic achievement in students and this was possibly more marked than that seen with alcohol or marijuana use.¹⁴
• Crystalline MDMA is thought to be the cause of several drug-induced seizures and overdoses, due to its high purity (95-100%).
• One study reported the use of 'pre-loading' and 'post-loading' - the practice of consuming other substances to mitigate the negative effects of ecstasy.¹⁵

Ecstasy deaths

• There were 202 reported deaths in the UK between 1996-2002 related to the use of ecstasy, reaching a peak of 43 in 2001 in England and Wales alone.¹⁶ Data from the Office of National Statistics for the period 1993 to 2006 record a mean 33 deaths per year where MDMA was implicated and 17 where it was considered the sole drug.³ One case of a death following ingestion of one tablet has been reported.³ A recent review of the literature concluded that the number of deaths related to ecstasy alone was small.⁷
• Fatal episodes are thought to be caused by three main mechanisms:
  • Hyperthermia - this is thought to cause the majority of deaths. It is often due to energetic dancing in an overheated club combined with the effect of MDMA on the thermostatic control mechanism of the autonomic nervous system.⁷
  • Dilutional hyponatraemia - this appears to be the result of ecstasy stimulating the production of anti-diuretic hormone, leading to fluid retention. The situation is sometimes compounded by users drinking a high volume of water rapidly in the mistaken belief that this will stave of the adverse effects of the drug.¹⁷
  • Cardiac failure - this may be due to a combination of factors, including tachycardia, hypertension and fluid retention.¹⁸

• The prevention of ecstasy abuse needs to be taken in the context of wider campaigns to reduce the use of illegal substances in the community, since crime prevention statistics confirm that, if the supply of one drug is restricted, abusers simply switch to another drug.⁵ Local drug education and prevention initiatives have been set up with Government funding to provide services in school and community settings.
• Testing kits designed to test that ecstasy pills are free from other contaminants are used in some clubs in Holland but have been criticised by the UK government as they appear to condone drug use. However, they are available via the internet.¹⁹
• 'Safer dancing' campaigns are encouraging clubs to provide 'chill out' areas, ensure there is a plentiful supply of water and arrange for staff to have first aid training. However, the message still needs to get across that water should be sipped slowly (no more than a pint an hour) and not drunk quickly in large quantities.