The drug MDMA (3,4-Methylenedioxymethamphetamine) goes by several street names including Molly, XTC, and ecstasy. An early book describing the drug in detail, Ecstasy: The Clinical, Pharmacological, and Neurotoxicological Effects of the Drug MDMA, classifies the drug as a dissociative hallucinogenic drug. Dissociative hallucinogenic drugs produce similar effects to other hallucinogens, such as LSD or mescaline, and also often produce certain sensations that consist of stimulant-like properties and the feeling as if one is leaving their own body, as if things around them are not real, or as if they are outside of reality looking in. These effects are commonly referred to as dissociative effects.
Ecstasy was a very popular club drug during the latter part of the 1980s and up until the recent early 2000s, but its popularity has declined somewhat. Often, ecstasy is referred to as a “rave drug” as a result of its popularity among individuals attending raves, dance parties, and clubs.
Despite the initial use of MDMA in the treatment of psychiatric disorders like PTSD and ongoing research studies investigating the potential of the drug to treat numerous psychiatric issues (e.g., issues with anxiety), the Drug Enforcement Agency (DEA) classifies MDMA as a Schedule I controlled substance. This classification indicates that the federal government considers the drug to have no potential medicinal uses, to be a significant drug of abuse, and to carry significant potential for the development of physical dependence in individuals who use it.
The Effects of Ecstasy
MDMA is a synthetic drug that has similarities to both hallucinogenic drugs and stimulant drugs like amphetamine. Originally, the main ingredient in drugs labeled by users as “ecstasy” was MDMA. The tablets or powders sold on the street often consisted of 30-40 percent MDMA and bulking/cutting agents. Currently, drugs sold as Molly or ecstasy are most likely not solely MDMA and cutting agents; they likely contain other drugs like amphetamine or other hallucinogenic-type drugs. The National Institute on Drug Abuse (NIDA) reports that many forms of drugs marketed as ecstasy today are not pure and contain other drugs like ketamine, bath salts (cathinones), other hallucinogenic drugs, methamphetamine, and even cocaine.
Per NIDA, the effects of ecstasy are outlined below.
- Ecstasy results in increased feelings of wellbeing, euphoria, and an increase in sociability. The drug also has a reputation for being able to enhance an individual’s sexual prowess, and this may be due to its stimulant effects.
- Stimulant effects of the drug lead to feelings of increased energy.
- In some instances, individuals may experience hallucinations and dissociative effects.
- A significant rise in body temperature (hyperthermia) is associated with the drug. Ecstasy activates the sympathetic nervous system, the division of the peripheral nervous system that is generally considered to speed up various bodily functions. In a person who takes ecstasy, this sympathetic nervous system activation results in an increase in body temperature. Hyperthermia can be potentially dangerous when individuals use the drug in crowded situations with little ventilation. This can result in the individual becoming overheated and dehydrated.
- Some individuals may experience other physical effects that can include a significant loss of appetite, teeth grinding as a result of the stimulant effects of the drug, nausea, vomiting, muscle cramps, blurred vision, and issues with sleep (particularly issues with disrupted REM sleep, which can result in issues with fatigue).
- Chronic use of the drug is associated with a significant risk for cardiovascular issues, including high blood pressure, rapid or irregular heartbeat, heart attack, and other issues, such as kidney damage and damage to the liver.
- In addition to the dissociative hallucinogenic effects of the drug, individuals who use ecstasy may also experience increased aggression, an increase in impulsive behavior, irritability, and issues with anxiety or depression, particularly when an individual has stopped using the drug. Using MDMA results in significant releases in neurotransmitters, such as dopamine, serotonin, norepinephrine, etc., and once the individual stops using the drug, these neurotransmitters become depleted in the central nervous system. This results in a “crash” that is often experienced as severe apathy, depression, and issues with anxiety.
Chronic users of MDMA who experience repeated cycles of massive neurotransmitter release followed by significant depletions of neurotransmitters in their central nervous system may experience substantial alterations in the neuropathways of the brain. Chronic users of ecstasy have demonstrated significant cognitive issues that may reflect the development of severe neurobiological changes, including issues with recent memory, trouble problem-solving, attention issues, and depression.
- The majority of sources indicate that tolerance to MDMA develops quickly. Individuals soon find that they need more of the drug to produce similar effects that they once got with much lower doses. Tolerance to a drug often results in individuals using escalating amounts of the drug that would be potentially dangerous to other individuals. Chronic use of the drug and the development of tolerance may lead to a significant substance use disorder that affects other areas of life.
Ecstasy and Physical Dependence
Many people are still under the misimpression that a person diagnosed with an addiction or a substance use disorder will automatically have developed physical dependence on their substance of choice. This is not true. The development of physical dependence (displaying both tolerance and withdrawal) is neither a necessary condition for a diagnosis of a substance use disorder, nor is it sufficient to have developed physical dependence on a substance in order to be diagnosed with a substance use disorder. The symptoms of physical dependence can serve as diagnostic criteria to determine if an individual may or may not have a substance use disorder; however, other issues regarding the person’s use of the substance must also be present.
One issue that often rules out the development of a substance use disorder even in the presence of physical dependence is the use of a particular drug or medication under the supervision of a physician and according to its prescribed purposes. Even individuals who use certain drugs under their prescribed instructions and under a physician’s supervision may develop physical dependence on the drug, but these individuals would not be diagnosed with an addiction or substance use disorder. A substance use disorder requires that the individual uses the drug for nonmedicinal purposes, develops significant stress or dysfunction as a result of their drug use, and satisfies certain diagnostic criteria.
NIDA reports that chronic use of ecstasy (MDMA) may lead to physical dependence; however, numerous research studies and professional sources report that while tolerance to MDMA does develop, chronic use of the drug does not result in the development of a significant withdrawal syndrome. Because individuals must display both tolerance and withdrawal symptoms in order to have developed physical dependence on a drug, it is questionable whether chronic use of MDMA can result in true physical dependence.
It is clear that chronic users of MDMA do often experience significant issues with depression, apathy, anxiety, loss of motivation, and cravings for the drug when they discontinue its use. As stated above, MDMA use triggers a massive release of neurotransmitters in the brain and once the individual discontinues their use of the drug, these neurotransmitters become severely depleted. The emotional effects associated with discontinuation of the drug may be due to this neurotransmitter depletion and not due to the development of true physical dependence on the drug. For example, individuals who chronically abuse stimulant drugs like cocaine or methamphetamine experience similar “crashes.”
Discontinuation of ecstasy may also result in severe emotional states that can cause an individual to engage in impulsive behaviors, have accidents, or even become suicidal as a result of severe depression and feelings of hopelessness. Thus, while it appears that there is no formal withdrawal syndrome associated with the discontinuation of ecstasy, this does not mean that individuals do not experience issues once they stop using the drug. Any person who has been a regular user of ecstasy should consult with a licensed mental health clinician before they stop using the drug in order to prepare for the severe emotional and psychological issues associated with discontinuation.
MDMA (Ecstasy) Overdose
- Blurred vision and dilated pupils
- Significant overheating that may be accompanied by significant perspiration and intense feelings of thirst
- Increased heartbeat
- Alterations in blood pressure that can include either hypertension or hypotension
- Muscle aches, cramps, teeth grinding, clenching of the jaw, or even a locked jaw
- Nausea, vomiting, fever, dizziness, or issues with balance and coordination
- Drowsiness, issues with concentration, issues with memory, confusion, irritability, agitation, paranoia, and/or visual hallucinations
- A loss of consciousness or a comatose state
- The potential for the development of seizures
People who become excessively thirsty and dehydrated may consume excessive amounts of fluid that can result in the development of hyponatremia, a decreased concentration of sodium and other substances in the body that can be serious and even potentially fatal. Research literature suggests that overdosing on MDMA is associated with fatalities due to seizures, other complications, and coma. Other potentially serious issues that can occur as a result of an overdose on ecstasy include:
- Heart failure due to cardiac arrhythmia
- Renal failure
- Respiratory distress
- Liver damage
- Rhabdomyolysis or the deterioration of muscle tissue resulting in the release of proteins and other substances in the bloodstream that can lead to the development of kidney failure or severe kidney damage
Treatment for an overdose on ecstasy often consists of:
- The use of benzodiazepines to treat seizures, agitation, and muscle cramps or spasms
- Sorbitol or activated charcoal to remove any remaining drugs from the individual’s intestines
- Attempts to lower the individual’s body temperature that can include moving the individual to a room with better ventilation, the use of fans or air-conditioning, or spraying individuals with cool water
- The administration of IV fluids to treat dehydration and other issues
- Stabilizing cardiovascular problems with medications
- Sedation or restraints for individuals who are aggressive or agitated
If one suspects that an individual has overdosed on ecstasy, it is important to immediately call 911, remain with the person, and try to remain calm and reassure the person. If the individual is agitated or overheated, try and change their environment to a more suitable environment (e.g., an environment with less stimulation, fewer people, or one that is well ventilated or air-conditioned), and attempt to keep the person hydrated. Allow the person to sip fluids but do not allow them to gulp fluids or to drink excessive amounts of liquid.
The Development of a Substance Use Disorder as a Result of Ecstasy Abuse
Individuals who chronically abuse ecstasy may be diagnosed with a substance use disorder. Based on the diagnostic criteria for substance use disorders by the American Psychiatric Association (APA), the particular substance use disorder that would be diagnosed in an individual who abused ecstasy would be a hallucinogen use disorder. The symptoms of a hallucinogen use disorder consist of:
- Significant issues controlling use of the hallucinogen (e.g., ecstasy), including:
- Frequently using the drug for longer periods of time or in greater amounts than originally intended
- Spending significant amounts of time using the drug, trying to get the drug, or recovering from using the drug
- Frequently using the drug in situations where it is hazardous or dangerous to use
- Giving up important activities in favor of using the drug
- Numerous attempts to cut down or stop using the drug but being unable to do so
- Continuing to use the drug even though one is aware that their drug use is causing them physical and/or psychological issues
- Continuing to use the drug in spite of the fact that the drug use is affecting one’s performance at work, in school, or another important areas of life
- Frequently experiencing significant cravings for the drug
- Significant distress or impairment in important areas of life
- The development of significant tolerance to ecstasy
The formal diagnosis of a hallucinogen use disorder can only be made by a licensed mental care clinician. There are other signs that might suggest that an individual is abusing a drug like ecstasy that do not represent manifestations of the formal diagnostic criteria. According to NIDA and the American Society of Addiction Medicine (ASAM), some of these signs include:
- The person is extremely gregarious or sociable at parties, clubs, etc., and displays uncharacteristic levels of energy and talkativeness in these situations. These episodes are often followed by periods of isolation, irritability, lethargy, the need for excessive sleep, and depression.
- The above pattern is accompanied by a tendency for the individual to perspire profusely and even overheat in social situations when the individual does not have a history of doing so.
- The person displays alternating patterns of confusion, poor memory, and even complaints of seeing or hearing things that are not there that are accompanied by increased levels of energy followed by periods of lethargy and decreased mood.
Treatment for Ecstasy Addiction
The treatment protocol for an individual with a diagnosis of a hallucinogen use disorder as a result of ecstasy abuse would consist of:
- Assessment: A thorough assessment is needed to identify any co-occurring mental health or medical issues and to develop an understanding of the individual’s social situation.
- Medical care: Initial medical management of issues with anxiety and depression that may be associated with discontinuing the drug is needed. Medications can be used to deal with cravings if they are needed.
- Therapy: Enrollment in a formal substance use disorder therapy program is necessary to address the individual’s substance use disorder. The program should include elements of psychoeducation regarding substance abuse, stress management, the development of coping skills to aid in relapse prevention, and the development of a long-term plan to maintain abstinence. Cognitive Behavioral Therapy is the preferred form of intervention.
- Social support from family and friends: Some individuals can become involved in family therapy if the situation warrants it, whereas others can simply receive direct support from family and friends. Developing a new peer group is often extremely important for individuals who abuse drugs. This can occur in a number of different contexts, including becoming involved in social support groups, such as 12-Step groups. These groups are also excellent sources of long-term aftercare treatment; therapy is typically time-limited, whereas social support group participation is ongoing.
- Other supports and interventions are needed, as appropriate for the individual case.
It is extremely important for individuals to remain in treatment or be involved in treatment-related activities (e.g., social support group involvement) for a sufficient length of time. Often, this can be for years. According to ASAM and NIDA, success in recovery is strongly related to the length of time an individual remains in treatment. Individuals who stay in some form of treatment or aftercare for at least 5-7 years following discontinuation of their drug of choice have the greatest long-term success rates in recovery.