MDMA - Ecstasy: A Current Overview Introduction MDMA (3,4-methylenedioxy-methamphetamine) is a synthetic stimulant that alters a person’s perception and mood. A person using MDMA will have an altered awareness of surrounding objects and conditions. The drug is similar chemically to hallucinogens and stimulants. It can produce feelings of increased pleasure, energy, emotional warmth, and a distorted perception of time. Although MDMA has psychedelic effects that cause a sense of euphoria and increased energy, over the long-term the drug may lead to fatigue and depression. MDMA is often combined with other drugs, which increases its potentially harmful effects on the user. Because of these harmful effects, MDMA was made illegal and listed as a Schedule I drug. Nevertheless, experimental use of MDMA has increased for psychiatric disorders, for example, posttraumatic stress disorder (PTSD), in an attempt to treat symptoms.5 The History And Evolving Use Of MDMA Anton Kollisch discovered MDMA in Germany in 1912. Kollisch was a chemist working for the German pharmaceutical company Merck. The research interest in the drug was to synthesize methylhydrastinine as a possible treatment for uterine bleeding.6 Ecstasy was patented in 1914 by Merck and was used in therapy. Major tests for MDMA took place in the 1950s at the University of Michigan for the U.S. Army to study its toxicity in animals. In the mid 1970s the substance came to the attention of Alexander Shulgin. Shulgin was a former chemist with Dow Chemical Company and he is known 1 ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com as the godfather of Ecstasy. MDMA came to his attention when he was researching another psychoactive compound called MDA. Shulgin worked with David Nichols from Perdue University and in 1978 they published a report about the effects of MDMA in humans. They compared the drug to mushrooms and marijuana.The report by Shulgin and Nichols caught the attention of psychotherapists interested in the disinhibiting effects of MDMA. They saw the drug as a possible tool to overcome fear in patients. The drug was thought to increase patients’ insight into their emotions. Eventually, MDMA became the drug of choice within the rave culture, house parties, clubs, and festivals, and goes by the popular name Ecstasy or Molly.1-6 After MDMA was introduced into psychotherapy, people began using MDMA recreationally. MDMA became attractive recreationally because it has the effects of both a hallucinogenic drug and a stimulant. The name Ecstasy was coined because it described the drug’s effect on people. Production of the drug in the 1980s could not keep up with its use. Safrole and sassafras oil was used to manufacture MDMA. Initially popular at nightclubs and all-night dance parties known as raves, MDMA spread through networks including young, urban professionals (yuppies), users of psychedelics, psychiatrists, and psychotherapists. A psychedelic drug closely related to MDMA, methylenedioxyemphetamine (MDA), nicknamed Sally, spread to U.S. college campuses. Recreational users and psychotherapists were hopeful that MDMA and MDA would remain legal in the United States.1-6 MDMA: Schedule I Substance Because of the perceived, serious dangers of MDMA, in 1985 the United States Drug Enforcement Agency (DEA) issued an emergency notice declaring MDMA a Schedule I substance and the DEA also issued an alert to 2 ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com individuals and businesses that it was illegal in the U.S. to use safrole and sassafras oil to manufacture MDMA.7 Some psychiatrists and psychotherapists objected to the DEA classifying MDMA as it did. They cited anecdotal use of its benefits in their practices. These objections failed and in 1988 MDMA and similar psychedelic drugs were classified as Schedule I substances. The Schedule I classification is according to the federal Controlled Substances Act, which is part of the Comprehensive Drug Abuse Prevention and Control Act of 1970. Other examples of Schedule I drugs include heroin, LSD, peyote, and marijuana (cannabis).8 Under federal law, substances are categorized under schedules listed from Schedule I to Schedule V. Schedule I drugs are considered to be the most dangerous drugs. The schedule is assigned based on a drug’s 1) potential for abuse, 2) safety, 3) addictive potential, and 4) whether there is a legitimate medical application for the drug. The potential for severe psychological or physical addiction exists with Schedule I drugs and there is no legitimate medical application.8-10 No clinical studies have established the safety and efficacy of Ecstasy in a psychotherapy setting, which could make MDMA become a Schedule II drug, so the classification as a Schedule I drug remains. Statistics On MDMA Use Use of MDMA is reported at age 12 and older. There are indications that the peak age for use is between ages 18 to 25. There is less use above the age of 26 and under the age of 17. Statistics show that the use among adults 3 ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com may be decreasing overall but this may not be true of adolescents.2,3 This could be because younger users may think that MDMA provides a high that is safe; however, it is not safe. Table 1 Use of MDMA (%): Grade 8, 10, and 12 (2016) Drug Time period Grade 8 Grade 10 Grade 12 MDMA Lifetime 1.70 2.80 4.90 Past year 1.00 1.80 2.70 Past month 0.30 0.50 0.90 Table 2 MDMA % Use: Ages 12 and older, 12 - 17, 18 - 25, and 26 or older (2015) Time Period 12 and older 12 to 17 18 to 25 26 and older Lifetime 6.80 1.40 13.10 6.5 Past year 1.00 0.80 4.10 0.50 Past month 0.20 0.10 0.90 0.10 MDMA shares toxicities with amphetamines. It is also associated with specific adverse effects that can be serious or even lead to death. Deaths associated with the use of MDMA have increased since 2013.4 In other countries around the same time, such as Germany, the highest percent of MDMA reached increased for people aged 25 to 29. In Europe, in 2012 the estimate was that 37 percent of club goers ages 14 to 35 used MDMA.1-4 The cost of Ecstasy varies across the globe. Prices tend to be higher in North American than in Europe. A tablet of MDMA/Ecstasy in the United States can be as high as $50 for 50-150 mg of the drug. The lower prices can be $10 to 4 ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com $25 per tablet. Production of Ecstasy is mainly in Canada but it is also imported from China. High Risk Drugs And Substance Use Disorder Before beginning an in depth discussion of MDMA, Ecstasy/Molly, a review of the drugs known to have high risk to develop into a substance use disorder and addiction are raised here. It is important for clinicians to be aware of other substances known to commonly have a high risk of addiction as they are often combined with MDMA use and are co-occurring disorders that need to be diagnosed as multiple or poly-substance use disorders, which complicate the medical management and treatment plan for recovery. When determining drug of use, the medical guidelines for testing can vary between regions, however, the clinician diagnosing a problem of MDMA or co-occurring will need to review a laboratory drug screen. Five drugs considered most important in a routine drug screen have evolved over time, such as new variants of amphetamines, synthetic marijuana/cannabinoids, opioids, and PCP not detectable with a routine drug test. PCP has been reported to be relatively obscure and used with lower frequency than numerous other street drugs, and amphetamine use is relatively infrequent compared now with methamphetamine and amphetamine derivatives, such as MDMA (Ecstasy), MDPV (bath salts), and numerous other drugs in this class. It is important that clinicians stay abreast of the drugs reported as frequently used, as the popular notion of drug use evolves based on media report, supply, demand and cost.47 In the United States, currently only amphetamine, cocaine, marijuana, opioids, and PCP should be expected on drug screen test, unless otherwise 5 ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com specified or requested. Certain drugs and substances have strong potential for a substance use disorder while others do not. Drugs such as cocaine and heroin and substances such as alcohol are intensely psychoactive, and the user will prefer them for a more powerful feeling of being high. This is certainly one of the known reasons for why they are the agents of choice for people who develop a substance use disorder. However, the pleasures of being intoxicated or high cannot fully explain a substance use disorder, and research has shown that continued and excessive use of these harmful agents causes changes in the central nervous system. These changes both cause and reinforce substance use. Of course, there are many people who take illicit or prescription drugs and/or drink alcohol that do not develop a substance use disorder, and these individual responses to commonly used drugs and substances further complicate the efforts at understanding the development of a substance use disorder. The mechanism of action and medical consequences of long-term use of alcohol, amphetamines/stimulants, cocaine, opioids, and sedative-hypnotics are important considerations when starting and continuing a patient treatment plan. The mechanisms of action by which alcohol and specific high risk drugs cause a substance use disorder, and the withdrawal syndromes associated with each one, is highlighted below.46 Alcohol Aside from tobacco, alcohol is the most commonly used psychoactive drug in our society.