MDMA

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MDMA
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256px
Systematic (IUPAC) name
(RS)-1-(benzo[d][1,3]dioxol-5-yl)-N-methylpropan-2-amine
Clinical data
Pregnancy
category
Routes of
administration		 Oral, sublingual, insufflation, inhalation (vaporization), injection,[2] rectal
Legal status
Legal status
Pharmacokinetic data
Metabolism Hepatic, CYP450 extensively involved, especially CYP2D6
Biological half-life 6–10 (though duration of effects is typically actually 3–5 hours)
Excretion Renal
Identifiers
CAS Number 69610-10-2
ATC code none
PubChem CID 1615
ChemSpider 1556
Synonyms (±)-1,3-benzodioxolyl-N-methyl-2-propanamine;
(±)-3,4-methylenedioxy-N-methyl-α-methyl-2-phenethylamine;
DL-3,4-methylenedioxy-N-methylamphetamine;
methylenedioxymethamphetamine
Chemical data
Formula C11H15NO2
Molar mass 193.25 g/mol[[Script error: No such module "String".]]
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MDMA (3,4-Methylenedioxymethamphetamine, commonly known as ecstasy, often abbreviated "E" or "X") is an entactogenic drug of the phenethylamine and amphetamine families.

MDMA has a tendency to induce euphoria, a sense of intimacy with others, and diminished anxiety and depression. Many, particularly in the fields of psychology and cognitive therapy, have suggested MDMA might have therapeutic benefits and facilitate therapy sessions in certain individuals. Clinical trials are now testing the therapeutic potential of MDMA for post-traumatic stress disorder (PTSD) and anxiety associated with terminal cancer.[3][4]

MDMA is criminalized in most countries under a United Nations (U.N.) agreement,[5] and its possession, manufacture, or sale may result in criminal prosecution, although some limited exceptions exist for scientific and medical research. MDMA is one of the most widely used recreational drugs in the world[citation needed] and is taken in a variety of contexts far removed from its roots in psychotherapeutic settings. It is commonly associated with dance parties (or "raves") and electronic dance music.[6]

There have been debates within scientific, health care, and drug policy circles about the risks of MDMA, specifically the possibility of neurotoxic damage to the central nervous system (CNS). Regulatory authorities in several locations around the world have approved scientific studies administering MDMA to humans to examine its therapeutic potential and its effects.[7]

Continuing to study the substance in clinical trials, the Multidisciplinary Association for Psychedelic Studies released the following statement in October 2008, "We found that low doses of MDMA (between 50 and 75 mg) were both psychologically and physiologically safe for all the subjects. Future studies in larger samples and using larger doses are needed in order to further clarify the safety and efficacy of MDMA in the clinical setting in subjects with PTSD."[8]

The role of the United States government in creating many of the pervasive myths surrounding the drug, including the overstatement of its dangers, was sharply criticized in the television programme Ecstasy Rising, an ABC journalistic special program hosted by then-anchor Peter Jennings.

Terminology

MDMA was first introduced clinically under the names "Adam" and "Empathy" when it was used in psychotherapy in the late 1970s and early to mid 1980s.[9][self-published source?] Later on, upon making it into the recreational drug use scene, it came to be widely known as "ecstasy", often abbreviated as "E", "X", or "XTC".[9][self-published source?]

History

MDMA was first synthesized in 1912 by Merck chemist Anton Köllisch. At the time, Merck was interested in developing substances that stopped abnormal bleeding. Merck wanted to evade an existing patent, held by Bayer, for one such compound: hydrastinine. At the behest of his superiors Walther Beckh and Otto Wolfes, Köllisch developed a preparation of a hydrastinine analogue, methylhydrastinine. MDMA was an intermediate compound in the synthesis of methylhydrastinine, and Merck was not interested in its properties at the time.[10] On 24 December 1912 Merck filed two patent applications that described the synthesis of MDMA[11] and its subsequent conversion to methylhydrastinine.[12]

Over the following 65 years, MDMA was largely forgotten. Merck records indicate that its researchers returned to the compound sporadically. In 1927, Max Oberlin studied the pharmacology of MDMA and observed that its effects on blood sugar and smooth muscles were similar to ephedrine's. Researchers at Merck conducted experiments with MDMA in 1952 and 1959.[10] In 1953 and 1954, the United States Army commissioned a study of toxicity and behavioral effects in animals of injected mescaline and several analogues, including MDMA. These originally classified investigations were declassified and published in 1973.[13] The first scientific paper on MDMA appeared in 1958 in Yakugaku Zasshi, the Journal of the Pharmaceutical Society of Japan. In this paper, Yutaka Kasuya described the synthesis of MDMA, a part of his research on antispasmodics.[14]

MDMA was being used nonmedically in the United States by 1970.[15] In the mid-1970s, Alexander Shulgin, then at University of California, Berkeley, heard from his students about unusual effects of MDMA; among others, the drug had helped one of them to overcome his stutter. Intrigued, Shulgin synthesized MDMA and tried it himself in 1976.[16] Two years later, he and David Nichols published the first report on the drug's psychotropic effect in humans. They described "altered state of consciousness with emotional and sensual overtones" that can be compared "to marijuana,and to psilocybin devoid of the hallucinatory component".[17]

Shulgin took to occasionally using MDMA for relaxation, referring to it as "my low-calorie martini", and giving the drug to his friends, researchers, and other people whom he thought could benefit from it. One such person was psychotherapist Leo Zeff, who had been known to use psychedelics in his practice. Zeff was so impressed with the effects of MDMA that he came out of his semi-retirement to proselytize for it. Over the following years, Zeff traveled around the U.S. and occasionally to Europe, training other psychotherapists in the use of MDMA.[16][18][19] Among underground psychotherapists, MDMA developed a reputation for enhancing communication during clinical sessions, reducing patients' psychological defenses, and increasing capacity for therapeutic introspection.[citation needed]

In the early 1980s in the U.S., MDMA rose to prominence as "Adam" in trendy nightclubs and gay dance clubs in the Dallas area.[20] From there, use spread to raves in major cities around the country, and then to mainstream society. The drug was first proposed for scheduling by the Drug Enforcement Administration (DEA) in July 1984[21] and was classified as a Schedule I controlled substance in the U.S. on 31 May 1985.[22]

In the late 1980s MDMA, known by that time as "ecstasy", began to be widely used in the UK and other parts of Europe, becoming an integral element of rave culture and other psychedelic-influenced music scenes. Spreading along with rave culture, illicit MDMA use became increasingly widespread among young adults in universities and later in high schools. MDMA became one of the four most widely used illicit drugs in the U.S., along with cocaine, heroin, and cannabis.[citation needed] According to some estimates as of 2004, only marijuana attracts more first time users in the U.S.[23]

After MDMA was criminalized, most medical use stopped, although some therapists continued to prescribe the drug illegally. Later Charles Grob initiated an ascending-dose safety study in healthy volunteers. Subsequent legally-approved MDMA studies in humans have taken place in the U.S. in Detroit (Wayne State University), Chicago (University of Chicago), San Francisco (UCSF and California Pacific Medical Center), Baltimore (NIDA–NIH Intramural Program), and South Carolina, as well as in Switzerland (University Hospital of Psychiatry, Zürich), the Netherlands (Maastricht University), and Spain (Universitat Autònoma de Barcelona).[24]

In 2010 the BBC reported that use of MDMA had decreased in the UK in previous years. This is thought to be due to increased seizures and decreased production of the precursor chemicals used to manufacture MDMA. The availability of legal alternatives to MDMA such as mephedrone is also thought to have contributed to its decrease in popularity.[25]

Therapeutic use

There have long been suggestions that MDMA might be useful in psychotherapy, facilitating self-examination with reduced fear.[26][27][28] Indeed, some therapists, including Leo Zeff, Claudio Naranjo, George Greer, Joseph Downing, and Philip Wolfson, used MDMA in their practices until it was made illegal. George Greer synthesized MDMA in the lab of Alexander Shulgin and administered it to about 80 of his clients over the course of the remaining years preceding MDMA's Schedule I placement in 1985. In a published summary of the effects,[29] the authors reported patients felt improved in various, mild psychiatric disorders and other personal benefits, especially improved intimate communication with their significant others. In a subsequent publication on the treatment method, the authors reported that one patient with severe pain from terminal cancer experienced lasting pain relief and improved quality of life.[30] However, little evidence examining MDMA in psychotherapy practice have used methods that would be considered reliable or convincing in general scientific practice. For example, it is not known to what extent similar patients might improve by chance or from any comparable form of psychotherapy ie. there was no active control condition.

The possible therapeutic potential of MDMA is being tested in several ongoing studies, some sponsored by the Multidisciplinary Association for Psychedelic Studies (MAPS). Studies in the U.S., Switzerland, and Israel are evaluating the efficacy of MDMA-assisted psychotherapy for treating those diagnosed with post-traumatic stress disorder (PTSD) or anxiety related to cancer. MAPS reported provisonal results in a conference poster.[31].

Non-medical use

The European Monitoring Centre for Drugs and Drug Addiction notes that although there are some reports of tablets being sold for as little as €1, most countries in Europe now report typical retail prices in the range of €3 to €9 per tablet.[32] The United Nations Office on Drugs and Crime claimed in its 2008 World Drug Report that typical U.S. retail prices are lower, costing 10 to 15 dollars per tablet, or from 4 to 6 dollars per tablet if bought in batches.[33] MDMA is expensive in Australia, costing AU$20–AU$50 per tablet, but in the Asian community it is AU$20–30 depending on the size. In terms of purity data for Australian MDMA, the average is around 34%, ranging from less than 1% to about 85%. The majority of tablets contain 70–85 mg of MDMA. Most ecstasy enters Australia from different markets, the Netherlands, the UK, Asia and the U.S.[34]

Polysubstance use

Main article: Poly drug use

MDMA is occasionally known for being taken in conjunction with psychedelic drugs, such as LSD or psilocybin mushrooms, or even common drugs such as cannabis. As this practice has become more prevalent, most of the more common combinations have been given nicknames, such as "candy flipping", for MDMA combined with LSD[35], "hippie flipping" when combined with psilocybin mushrooms, and "kitty flipping" when combined with ketamine. Many users use mentholated products while taking MDMA for its cooling sensation while experiencing the drug's effects. Examples include menthol cigarettes, Vicks[36] and lozenges. This sometimes has deleterious results on the upper respiratory tract.[37]

Chemistry

File:MDMAjakarta.jpg
An industrial scale methamphetamine and MDMA chemical factory in Cikande, Indonesia.

Safrole, a colorless or slightly black oil, extracted from the root-bark or the fruit of sassafras plants is the primary precursor for all manufacture of MDMA. There are numerous synthetic methods available in the literature to convert safrole into MDMA via different intermediates.[38][39][40][41] One common route is via the MDP2P (3,4-methylenedioxyphenyl-2-propanone, also known as piperonyl acetone) intermediate. This intermediate can be produced in at least two different ways. One method is to isomerize safrole to isosafrole in the presence of a strong base and then oxidize isosafrole to MDP2P. Another, reportedly better[citation needed], method is to make use of the Wacker process to oxidize safrole directly to the MDP2P (3,4-methylenedioxy phenyl-2-propanone) intermediate. This can be done with a palladium catalyst. Once the MDP2P intermediate has been prepared, a reductive amination leads to MDMA, a racemate {1:1 mixture of (R)-1-(benzo[d][1,3]dioxol-5-yl)-N-methylpropan-2-amine and (S)-1-(benzo[d][1,3]dioxol-5-yl)-N-methylpropan-2-amine}. Another method for the synthesis of racemic MDMA is addition of hydrogen bromide to safrole and reaction of the adduct with methylamine.

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Relatively small quantities of essential oil are required to make large numbers of MDMA pills. The essential oil of Ocotea cymbarum typically contains between 80 and 94% safrole. This would allow 500 ml of the oil, which retails at between $20 and $100, to be used to produce an estimated 1,300 to 2,800 tablets containing approximately 120 mg of MDMA each.[42]

Pharmacology

For more details on this topic, see Effects of MDMA on the human body.

MDMA acts as a releasing agent of serotonin, norepinephrine, and dopamine.[43] It enters neurons via carriage by the monoamine transporters.[43] Once inside, MDMA inhibits the vesicular monoamine transporter, which results in increased concentrations of serotonin, norepinephrine, and dopamine into the cytoplasm,[44] and induces their release by reversing their respective transporters through a process known as phosphorylation.[45] It also acts as a weak 5-HT1 and 5-HT2 receptor agonist, and its more efficacious metabolite MDA likely augments this action.[46][47][48][49]

MDMA's unusual entactogenic effects have been hypothesized to be, at least partly, the result of indirect oxytocin secretion via activation of the serotonin system.[50] Oxytocin is a hormone released following events like hugging, orgasm, and childbirth, and is thought to facilitate bonding and the establishment of trust.[51] Based on studies in rats, MDMA is believed to cause the release of oxytocin, at least in part, by both directly and indirectly agonizing the serotonin 5-HT1A receptor. A placebo-controlled study in 15 human volunteers found that 100 mg MDMA increased blood levels of oxytocin and the amount of oxytocin increase was correlated with the subjective prosocial effects of MDMA.[52]

Pharmacokinetics

File:1g MDMA-HCl.jpg
MDMA crystals

MDMA reaches maximal concentrations in the blood stream between 1.5 and 3 hours after ingestion. It is then slowly metabolized and excreted, with levels decreasing to half their peak concentration over approximately 8 hours. Thus, there are still high MDMA levels in the body when the experiential effects have mostly ended, indicating that acute tolerance has developed to the actions of MDMA. Taking additional supplements of MDMA at this point therefore produces higher concentrations of MDMA in the blood and brain than might be expected based on the perceived effects.

Metabolites of MDMA that have been identified in humans include 3,4-methylenedioxyamphetamine (MDA), 4-hydroxy-3-methoxy-methamphetamine (HMMA), 4-hydroxy-3-methoxyamphetamine (HMA), 3,4-dihydroxyamphetamine (DHA) (also called alpha-methyldopamine (α-Me-DA)), 3,4-methylenedioxyphenylacetone (MDP2P), and N-hydroxy-3,4-methylenedioxyamphetamine (MDOH). The contributions of these metabolites to the psychoactive and toxic effects of MDMA are an area of active research. 65% of MDMA is excreted unchanged in the urine (additionally 7% is metabolized into MDA) during the 24 hours after ingestion.[53]

MDMA is known to be metabolized by two main metabolic pathways: (1) O-demethylenation followed by catechol-O-methyltransferase (COMT)-catalyzed methylation and/or glucuronide/sulfate conjugation; and (2) N-dealkylation, deamination, and oxidation to the corresponding benzoic acid derivatives conjugated with glycine. The metabolism may be primarily by cytochrome P450 (CYP450) enzymes (CYP2D6 (in humans, but CYP2D1 in mice), and CYP3A4) and COMT. Complex, nonlinear pharmacokinetics arise via autoinhibition of CYP2D6 and CYP2D8, resulting in zeroth order kinetics at higher doses. It is thought that this can result in sustained and higher concentrations of MDMA if the user takes consecutive doses of the drug.

Because the enzyme CYP2D6 is deficient or totally absent in some people[54], it was once hypothesized that these people might have elevated risk when taking MDMA. However, there is still no evidence for this theory and available evidence argues against it.[55] It is now thought that the contribution of CYP2D6 to MDMA metabolism in humans is less than 30% of the metabolism. Indeed, an individual lacking CYP2D6 was given MDMA in a controlled clinical setting and a larger study gave MDMA to healthy volunteers after inhibiting CYP2D6 with paroxetine. Lack of the enzyme caused a modest increase in drug exposure and decreases in some metabolites, but physical effects did not appear appreciably elevated. While there is little or no evidence that low CYP2D6 activity increases risks from MDMA, it is likely that MDMA-induced CYP2D inhibition will increase risk of those prescription drugs that are metabolized by this enzyme. MDMA-induced CYP2D inhibition appears to last for up to a week after MDMA exposure.

MDMA and metabolites are primarily excreted as conjugates, such as sulfates and glucuronides.[56]

File:NDMA-Formel.png
The (R)-enantiomer (top) and the (S)-enantiomer of MDMA

MDMA is a chiral compound and has been almost exclusively administered as a racemate. However, an early uncontrolled report suggests that the (S)-enantiomer is significantly more potent in humans than the (R)-enantiomer[57][58] indicate that the disposition of MDMA is stereoselective, with the S-enantiomer having a shorter elimination half-life and greater excretion than the R-enantiomer. For example, Fallon et al.[57] reported that the area under the blood plasma concentration versus time curve (AUC) was two to four times higher for the (R)-enantiomer than the (S)-enantiomer after a 40 mg oral dose in human volunteers. Similarly, the plasma half-life of (R)-MDMA was significantly longer than that of the (S)-enantiomer (5.8 ± 2.2 hours vs 3.6 ± 0.9 hours). However, because MDMA has dose dependent kinetics, it is likely that these half-lives would be higher at more typical doses (100 mg is sometimes considered a typical dose). Given as the racemate, MDMA has a half-life of around 8 hours.

Detection of use

MDMA and MDA may be quantitated in blood, plasma or urine to monitor for abuse, confirm a diagnosis of poisoning or assist in the forensic investigation of a traffic or other criminal violation or a sudden death. Some drug abuse screening programs rely on hair, saliva or sweat as specimens. Most commercial amphetamine immunoassay screening tests cross-react significantly with MDMA or its major metabolites, but chromatographic techniques can easily distinguish and separately measure each of these substances. The concentrations of MDA in the blood or urine of a person who has taken only MDMA are generally less than 10% those of the parent drug.[59][60][61]

Drug interactions

There are a number of reported potentially dangerous possible interactions between MDMA and other drugs. Several cases have been reported of death in individuals who ingested MDMA while taking ritonavir (Norvir), which inhibits multiple CYP450 enzymes. Toxicity or death has also been reported in people who took MDMA in combination with certain monoamine oxidase inhibitors (MAOIs) such as phenelzine (Nardil), tranylcypromine (Parnate), or moclobemide (Aurorix, Manerix).[62] On the other hand, MAOB inhibitors like selegiline (Deprenyl; Eldepryl, Zelapar, Emsam) do not seem to carry these risks when taken at selective doses, and have been used to completely block neurotoxicity in rats.[63]

People taking any type of serotonin reuptake inhibitor (SRI) on a chronic basis commonly find that the psychedelic and entactogenic effects of MDMA are near fully abolished, leaving merely stimulation instead. Many people attempt taking a dose around 3x as high and this appears to work as a remedy for the problem to some degree. Additionally, upon discontinuation of the prolonged administration of the SRI in question, such individuals may still not be able to properly experience the full desired effects of MDMA at normal doses for anywhere from a few weeks to as long as several months.

There is a possible risk of experiencing serotonin syndrome if MDMA is combined with another serotonergic drug.[64]

Commercial sassafras oil generally is a by-product of camphor production in Asia or comes from related trees in Brazil. Safrole is a precursor for the clandestine manufacture of MDMA (ecstasy), and as such, its transport is monitored internationally. Roots of Sassafras can also be steeped to make tea and were used in the flavoring of traditional root beer until being banned for mass production by the FDA. Laboratory animals that were given oral doses of sassafras tea or sassafras oil that contained large doses of safrole developed permanent liver damage or various types of cancer. In humans liver damage can take years to develop and it may not have obvious signs.

Effects

For more details on this topic, see Effects of MDMA on the human body.
File:Ecstacy monogram.jpg
Illicit tablets containing MDMA
File:Ecstasy.jpg
MDMA capsules and pressed tablets

The primary effects attributable to MDMA consumption are predictable and fairly consistent amongst users. Generally, users report feeling effects within 30–60 minutes of consumption, hitting a peak at approximately 1–1.5 hours, reaching a plateau that lasts about 2–3 hours, followed by a comedown of a few hours which may be accompanied by fatigue and minor effects.[65][66][67]

Subjective effects

The most common effects reported by users include:[68]

Side effects

In January 2001, an overview of the subjective side effects of MDMA was published by Liechti, Gamma, and Vollenweider in the journal Psychopharmacology. Their paper was based on clinical research conducted over several years involving 74 healthy volunteers.

The researchers found that there were a number of common side effects and that many of the effects seemed to occur in different amounts based on gender. The top side effects reported were difficulty concentrating, jaw clenching, grinding of the teeth during sleep, lack of appetite, and dry mouth/thirst (all occurring in more than 50% of the 74 volunteers).

Liechti, et al. also measured some of the test subjects for blood pressure, heart rate, and body temperature against a placebo control. No statistically significant changes were seen.[69][70]

After effects

Effects reported by some users once the acute effects of MDMA have worn off include:

  • Psychological
    • Anxiety and paranoia[71]
    • Depression[71][72][73][74][75][76]
    • Irritability[74]
    • Fatigue[75][76]
    • Impaired attention, focus, and concentration,[73] as well as drive and motivation (due to depleted serotonin levels)[72]
    • Residual feelings of empathy, emotional sensitivity, and a sense of closeness to others (afterglow)

When they occur, these after subacute effects are typically reported to last up to 3 to 7 days, with the exception of depression, which in some cases has become chronic.

Overdose

Upon overdose, the potentially serious serotonin syndrome, stimulant psychosis, and/or hypertensive crisis, among other dangerous adverse reactions, may come to prominence, the symptoms of which can include the following:

Chronic use

Some studies indicate that repeated recreational users of MDMA have increased rates of depression and anxiety, even after quitting the drug.[79][80] Meta-analytic reviews of the published literature on memory show that ecstasy users suffer significant short-term and long-term verbal memory impairment—with 70-80% of ecstasy users displaying significantly impaired memory. Moreover, this research shows that the memory impairment is not proportional to the lifetime number of tablets consumed and so, may occur with relatively low usage.[81]. Other meta analyses have also reported significant impairment of wider aspects of cognitive function, such as executive function.[82] Many factors, including total lifetime MDMA consumption, the duration of abstinence between uses, the environment of use, poly-drug use/abuse, quality of mental health, various lifestyle choices, and predispositions to develop clinical depression and other disorders may contribute to various possible health consequences. MDMA use has been occasionally associated with liver damage,[83] excessive wear of teeth,[84] and (very rarely) hallucinogen persisting perception disorder.[85]

Legal issues

MDMA is legally controlled in most of the world under the UN Convention on Psychotropic Substances and other international agreements, although exceptions exist for research. Generally, the unlicensed use, sale or manufacture of MDMA are all criminal offenses.

United Kingdom

MDMA was made illegal in 1977 by a modification order to the existing Misuse of Drugs Act 1971. Although MDMA was not named explicitly in this legislation, the order extended the definition of Class A drugs to include various ring-substituted phenethylamines,[86] thereby making it illegal to sell, buy, or possess the drug without a license. Penalties include a maximum of seven years and/or unlimited fine for possession; life and/or unlimited fine for production or trafficking. See list of drugs illegal in the UK for more information. In February 2009 an official independent scientific advisory board to the UK government recommended that MDMA be re-classified to Class B, but this recommendation was immediately rejected by the government (see Recommendation to downgrade MDMA). This 2009 report on MDMA stated:[87]

The original classification of MDMA in 1977 under the Misuse of Drugs Act 1971 as a Class A drug was carried out before it had become widely used and with limited knowledge of its pharmacology and toxicology. Since then use has increased enormously, despite it being a Class A drug. As a consequence, there is now much more evidence on which to base future policy decisions.... Recommendation 1: A harm minimisation approach to the widespread use of MDMA should be continued.... Recommendation 6: MDMA should be re-classified as a Class B drug.

United States

In the U.S., MDMA was legal and unregulated until 31 May 1985, at which time it was emergency scheduled to DEA Schedule I, for drugs deemed to have no medical uses and a high potential for abuse. During DEA hearings to schedule MDMA, most experts recommended DEA Schedule III prescription status for the drug, due to beneficial usage of MDMA in psychotherapy. The Administrative Law Judge (ALJ) overseeing the hearings, Francis Young, also recommended that MDMA be placed in Schedule III. The DEA then classified MDMA as Schedule I.[88][89] However, in Grinspoon v. Drug Enforcement Administration, 828 F.2d 881 (1st Cir. 1987), the First Circuit Court of Appeals remanded the scheduling determination for reconsideration by the DEA.[90] MDMA was temporarily removed from Schedule I.[91] Ultimately, in 1988, the DEA re-evaluated its position on remand and subsequently placed MDMA into Schedule I of the Controlled Substances Act.[92] In 2001, responding to a mandate from the U.S. Congress, the U.S. Sentencing Commission, resulted in an increase in the penalties for MDMA by nearly 3,000%,[93] despite scientific protest calling for a decrease in the penalties for MDMA possession and distribution.[94] The increase makes 1 gram of MDMA (four pills at 250 mg per pill's total weight regardless of purity, standard for Federal charges) equivalent to 1 gram of heroin (approximately fifty doses) or 2.2 pounds (1 kg) of cannabis for sentencing purposes at the federal level.[95] See also the RAVE Act of 2003.

World Health Organization

In 1985 the World Health Organization's Expert Committee on Drug Dependence recommended that MDMA be placed in Schedule I of the 1971 Convention on Psychotropic Substances, despite noting:[96]

No data are available concerning its clinical abuse liability, nature and magnitude of associated public health or social problems.

The decision to recommend scheduling of MDMA was not unanimous:[96]

One member, Professor Paul Grof (Chairman), felt that the decision on the recommendation should be deferred awaiting, in particular, the data on the substance's potential therapeutic usefulness and that at this time international control is not warranted.

The 1971 Convention has a provision in Article 7(a) that allows use of Schedule I drugs for "scientific and very limited medical purposes." The committee's report stated:[96][97]

The Expert Committee held extensive discussions concerning therapeutic usefulness of 3,4 Methylenedioxymethamphetamine. While the Expert Committee found the reports intriguing, it felt that the studies lacked the appropriate methodological design necessary to ascertain the reliability of the observations. There was, however, sufficient interest expressed to recommend that investigations be encouraged to follow up these preliminary findings. To that end, the Expert Committee urged countries to use the provisions of article 7 of the Convention on Psychotropic Substances to facilitate research on this interesting substance.

Health concerns

Main article: Effects of MDMA on the human body
File:Rational scale to assess the harm of drugs (mean physical harm and mean dependence).svg
Relative physical harm and dependence of ecstasy (the British medical journal The Lancet)[98]

While the short-term adverse effects and contraindications of MDMA are fairly well known, there is significant debate within the scientific and medical communities regarding possible long-term physical and psychological effects of MDMA.

Short-term health concerns

Short-term physical health risks of MDMA consumption include hyperthermia,[99][100] and hyponatremia.[101] Continuous activity without sufficient rest or rehydration may cause body temperature to rise to dangerous levels, and loss of fluid via excessive perspiration puts the body at further risk as the stimulatory and euphoric qualities of the drug may render the user oblivious to their energy expenditure for quite some time. Diuretics such as alcohol may exacerbate these risks further. Although one study[102] argues that MDMA itself causes fluid retention and increased body temperature, while alcohol is a diuretic and lowers the body temperature. Therefore, it is possible that a small amount of alcohol may help counteract a few of the adverse effects of MDMA.

Long-term effects on serotonin and dopamine

MDMA causes a reduction in the concentration of serotonin transporters (SERTs) in the brain. The rate at which the brain recovers from serotonergic changes is unclear. One study demonstrated lasting serotonergic changes in animals occurring due to MDMA exposure[103]. Other studies have suggested that the brain may recover from serotonergic damage.[104][105]

Some studies show that MDMA may be neurotoxic in humans.[106][107] Other studies, however, suggest that any potential brain damage may be at least partially reversible following prolonged abstinence from MDMA.[105][108] However, other studies suggest that SERT-depletion arises from long-term MDMA use due to receptor down-regulation, rather than true neurotoxicity.[109] Depression and deficits in memory have been shown to occur more frequently in long-term MDMA users.[110][111] However, some recent studies have suggested that MDMA use may not be associated with chronic depression.[112][113]

One study on MDMA toxicity, by George A. Ricaurte of Johns Hopkins School of Medicine, which claimed that a single recreational dose of MDMA could cause Parkinson's Disease in later life due to severe dopaminergic stress, was actually retracted by Ricaurte himself after he discovered his lab had administered not MDMA but methamphetamine, which is known to cause dopaminergic changes similar to the serotonergic changes caused by MDMA.[114] Ricaurte blamed this mistake on a labeling error by the chemical supply company that sold the material to his lab, but the supply company responded that there was no evidence of a labeling error on their end. Most studies have found that levels of the dopamine transporter (or other markers of dopamine function) in MDMA users deserve further study or are normal.[115][116][117][118][119][120][121]

Purity and dosage of "ecstasy"

File:Ecstasy MDMA Molly.jpg
MDMA powder

Another concern associated with MDMA use is toxicity from chemicals other than MDMA in ecstasy tablets. Due to its near-universal illegality, the purity of a substance sold as ecstasy is unknown to the typical user. The MDMA content of tablets varies widely between regions and different brands of pills and fluctuates somewhat each year. Pills may contain other active substances meant to stimulate in a way similar to MDMA, such as amphetamine, methamphetamine, ephedrine, or caffeine, all of which may be comparatively cheap to produce and can help to boost overall profits. In some cases, tablets sold as ecstasy do not even contain any MDMA. Instead they may contain an assortment of presumably undesirable drugs and substances, such as paracetamol, ibuprofen, talcum powder, etc.[122]

There have been a number of deaths attributed to PMA, a potent and highly neurotoxic hallucinogenic amphetamine, being sold as ecstasy.[123][124] PMA is unique in its ability to quickly elevate body temperature and heart rate at relatively low doses, especially in comparison to MDMA. Hence, a user who believes he is consuming two 120 mg pills of MDMA could actually be consuming a dose of PMA that is potentially lethal, depending on the purity of the pill. Not only does PMA cause the release of serotonin, but also acts as a monoamine oxidase inhibitor, MAOI. When combined with an MDMA or an MDMA-like substance, serotonin syndrome can result.[125] Combining MAO inhibitors with certain legal prescription and over the counter medications can also lead to (potentially fatal) serotonin syndrome.

Harm assessment

The chief executive of the UK Medical Research Council stated that MDMA is "on the bottom of the scale of harm", and was rated to be of lesser concern than alcohol, tobacco, as well as several classes of prescription medications, when examining the harmfulness of twenty popular recreational drugs. The UK study placed great weight on the risk for acute physical harm, the propensity for physical and psychological dependency on the drug, and the negative familial and societal impacts of the drug. - They did not evaluate or rate the negative impact of ecstasy on the cognitive health of ecstasy users e.g. poorer memory. Based on these factors, the study placed MDMA at number 18 in the list of 20 popular drugs.[126]

David Nutt, a former chairman of the UK Advisory Council on the Misuse of Drugs, stated in the Journal of Psychopharmacology in January 2009 that ecstasy use compared favorably with horse riding in terms of risk, with ecstasy leading to around 30 deaths a year in the UK compared to about 10 from horse riding, and "acute harm to person" occurring in approximately 1 in 10,000 episodes of ecstasy use compared to about 1 in 350 episodes of horse riding.[127] Dr. Nutt notes the lack of a balanced risk assessment in public discussions of MDMA:[127]

The general public, especially the younger generation, are disillusioned with the lack of balanced political debate about drugs. This lack of rational debate can undermine the trust in government in relation to drug misuse and thereby undermining the government's message in public information campaigns. The media in general seem to have an interest in scare stories about illicit drugs, though there are some exceptions (Horizon, 2008).[128] A telling review of 10-year media reporting of drug deaths in Scotland illustrates the distorted media perspective very well (Forsyth, 2001).[129] During this decade, the likelihood of a newspaper reporting a death from paracetamol was in [sic] per 250 deaths, for diazepam it was 1 in 50, whereas for amphetamine it was 1 in 3 and for ecstasy every associated death was reported.

A spokesperson for the ACMD clarified that "The recent article by Professor David Nutt published in the Journal of Psychopharmacology was done in respect of his academic work and not as chair of the ACMD."[130]

Recommendation to downgrade MDMA to Class B in the UK (Feb 2009)

In 2000, the UK Police Foundation issued the Runciman Report which reviewed the medical and social harms of MDMA and recommended: "Ecstasy and related compounds should be transferred from Class A to Class B."[131] In 2002, the Home Affairs Committee of the UK House of Commons, issued a report, The Government's Drugs Policy: Is it working?, which also recommended that MDMA should be reclassified to a Class B drug.[132] The UK government rejected both recommendations, saying that re-classification of MDMA would not be considered without a recommendation from the Advisory Council on the Misuse of Drugs, the official UK scientific advisory board on drug abuse issues.[133]

In February 2009, the UK Advisory Council on the Misuse of Drugs issued A review of MDMA ('ecstasy'), its harms and classification under the Misuse of Drugs Act 1971, which recommended that MDMA be re-classified in the UK from a class A drug to a class B drug.[87]

From the Discussion section of the ACMD report on MDMA:

Physical harms: (10.2) Use of MDMA is undoubtedly harmful. High doses may lead to death: by direct toxicity, in situations of hyperthermia/dehydration, excessive water intake, or for other reasons. However, fatalities are relatively low given its widespread use, and are substantially lower than those due to some other Class A drugs, particularly heroin and cocaine. Although it is no substitute for abstinence, the risks can be minimised by following advice such as drinking appropriate amounts of water (see Annex E). (10.3) Some people experience acute medical consequences as a result of MDMA use which can lead to hospital admission, sometimes with the requirement for intensive care. MDMA poisonings are not currently increasing in number and are less frequent than episodes due to cocaine. (10.4) MDMA appears not to have a high propensity for dependence or withdrawal reactions although a number of users seek help through treatment services. (10.5) MDMA appears to have little acute or enduring effect on the mental health of the average user, and unlike amphetamines and cocaine, it is seldom implicated in significant episodes of paranoia. (10.6) There is presently little evidence of longer-term harms to the brain in terms of either its structure or function. However, there is evidence for some small decline in a variety of domains, including verbal memory, even at low cumulative dose. The magnitude of such deficits appears to be small and their clinical relevance is unclear. The evidence shows that MDMA has been misused in the UK for 20 years but it should be noted that long-term effects of use cannot be ruled out. (10.7) Overall, the ACMD judges that the physical harms of MDMA more closely equate with those of amphetamine than of heroin or cocaine.

Societal harms: (10.8) MDMA use seems to have few societal effects in terms of intoxication-related harms or social disorder. However, the ACMD notes the very small proportion of cases where ‘ecstasy’ use has been implicated in sexual assault. (10.9) Disinhibition and impulsive, violent or risky behaviours are not commonly seen under the influence of MDMA, unlike with cocaine, amphetamines, heroin and alcohol. (10.10) The major issue for law enforcement is ‘ecstasy's’ position, alongside other Class A drugs, as a commodity favoured by organised criminal groups. It is therefore generally associated with a range of secondary harms connected with the trafficking of illegal drugs.

The UK Home Office rejected the recommendation of its independent scientific advisory board to downgrade MDMA to Class B, "saying it is not prepared to send a message to young people that it takes ecstasy less seriously".[134][135]

The government's veto was criticized in scientific publications. Colin Blakemore, Professor of Neuroscience, Oxford, stated in the British Medical Journal, "The government's decisions compromise its commitment to evidence based policy".[136] Also in response, an editorial in the New Scientist noted "A much larger percentage of people suffer a fatal acute reaction to peanuts than to MDMA.... Sadly, perspective is something that is generally lacking in the long and tortuous debate over illegal drugs."[137]

Environmental concerns

Demand for safrole, a substance used in the manufacture of MDMA, is causing rapid and illicit harvesting of the Cinnamomum parthenoxylon tree in Southeast Asia, in particular the Cardamom Mountains in Cambodia[138]. However, it is not clear what proportion of illicitly harvested safrole is going toward MDMA production, as over 90% of the global safrole supply (approx 2000 metric tons per year) is used to manufacture pesticides, fragrances, and other chemicals[139][140]. Sustainable harvesting of safrole is possible from leaves and sticks of certain plants.[139][140]

See also

References

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Further reading

External links

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Entactogens: 5-APDB • 6-APB • 6-APDB • IAP • MDA • MDEA • MDHMA (FLEA) • MDMA ("Ecstasy") • MDOH • MMDMA • NAP • TAP
Others: Amiflamine • D-Deprenyl • L-Deprenyl (Selegiline)
Phentermines
Stimulants: Chlorphentermine • Cloforex • Clortermine • Etolorex • Mephentermine • Pentorex (Phenpentermine) • Phentermine
Entactogens: MDPH • MDMPH
Cathinones
Stimulants: Amfepramone • Brephedrone • Buphedrone • Bupropion (Amfebutamone) • Cathinone (Propion) • Dimethylcathinone (Dimethylpropion, Metamfepramone) • Ethcathinone (Ethylpropion) • Flephedrone • Methcathinone (Methylpropion) • Mephedrone • Methedrone
Entactogens: Ethylone • Methylone
Phenylisobutylamines
Entactogens: 4-CAB • 4-MAB • Ariadne (α-Et-DOM) • BDB (J) • Butylone (bk-MBDB) • EBDB (Ethyl-J) • Eutylone (bk-EBDB) • MBDB (Methyl-J)
Stimulants: Phenylisobutylamine
Phenylalkylpyrrolidines
Stimulants: α-PBP • α-PPP • α-PVP • MDPBP • MDPPP • MDPV • MOPPP • MPBP • MPHP • MPPP • Naphyrone • PEP • Prolintane • Pyrovalerone
Catecholamines
(and relatives..)
6-FNE • 6-OHDA • α-Me-DA • α-Me-TRA • Adrenochrome • Ciladopa • D-DOPA (Dextrodopa) • Dopamine • Epinephrine (Adrenaline) • Epinine • Fenclonine • Ibopamine • L-DOPA (Levodopa) • L-DOPS (Droxidopa) • L-Phenylalanine • L-Tyrosine • meta-Octopamine • meta-Tyramine • Metanephrine • Metirosine • Methyldopa • Nordefrin (Levonordefrin) • Norepinephrine (Noradrenaline) • Normetanephrine • para-Octopamine • para-Tyramine
Miscellaneous

ca:MDMA de:MDMA es:MDMA eu:MDMA fr:MDMA he:אקסטזי hr:MDMA id:Metilendioksimetamfetamin it:MDMA nl:3,4-methyleendioxymethamfetamine ja:メチレンジオキシメタンフェタミン no:MDMA pl:3,4-metylenodioksymetamfetamina ro:MDMA ru:3,4-метилендиоксиметамфетамин sr:Екстази fi:MDMA sv:Ecstasy ur:مدما vi:Thuốc lắc

zh:MDMA
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  23. ↑ Primetime with Peter Jennings.
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  34. ↑ Drugtext - 10 years of ecstasy and other party drug use in Australia: What have we done and what is there left to do?
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  40. ↑ Reductive aminations of carbonyl compounds with borohydride and borane reducing agents. Baxter, Ellen W.; Reitz, Allen B. Organic Reactions (Hoboken, New Jersey, United States) (2002), 59
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  67. ↑ "MDMA Technical FAQ". TheDEA.org. May 2003. 
  68. ↑ Whetstone, Kobie J. (16 April 2009- 11 June 2009). "An Analysis of MDMA-Induced Neurotoxicity".  Check date values in: |date= (help)
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  78. ↑ "What Is Bruxism?". bruxism.org.uk. Retrieved May 25, 2010. 
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  80. ↑ Verheyden SL, Maidment R, Curran HV (2003). "Quitting ecstasy: an investigation of why people stop taking the drug and their subsequent mental health". J. Psychopharmacol. (Oxford). 17 (4): 371–8. doi:10.1177/0269881103174014. PMID 14870948. 
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  89. ↑ MDMA (Ecstasy) Law & Policy Center for Cognitive Liberty & Ethics
  90. ↑ Grinspoon v. Drug Enforcement Administration, 828 F.2d 881 (1st Cir. 1987)
  91. ↑ Schedules of Controlled Substances; Deletion of 3,4-Methylenedioxymethamphetamine (MDMA) From Schedule I of the Controlled Substances Act, 53 Fed. Reg. 2,225 (DEA 1988)
  92. ↑ Schedules of Controlled Substances; Scheduling of 3,4-Methylenedioxymethamphetamine (MDMA) Into Schedule I of the Controlled Substances Act; Remand, 53 Fed. Reg. 5,156 (DEA 22 Feb. 1988)
  93. ↑ SF Gate News 21 March 2001
  94. ↑ Federation of American Scientists MDMA Testimony (PDF)
  95. ↑ U.S. Federal Sentencing Guidelines (2007)
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  102. ↑ Dumont GJ, Kramers C, Sweep FC, Willemsen JJ,Touw DJ, Schoemaker RC, van Gerven JM, Buitelaar JK, Verkes RJ (2010). "Ethanol co-administration moderates 3,4-methylenedioxymethamphetamine effects on human physiology". J Psychopharmacol. 24(2) (2): 165–74. doi:10.1177/0269881108100020. PMID 19074534. 
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  106. ↑ Neurotoxicity at Dancesafe.org
  107. ↑ Does MDMA Cause Brain Damage?, Matthew Baggott, and John Mendelson
  108. ↑ Research on Ecstasy Is Clouded by Errors, Donald G. McNeil Jr., New York Times, 2 December 2003.
  109. ↑ "p-Chlorophenylalanine Changes Serotonin Transporter mRNA Levels and Expression of the Gene Product", Journal of Neurochemistry, 1996. Online copy (pdf)
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