Ecstasy

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PatientPlus articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use, so you may find the language more technical than the condition leaflets.

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] 3-4 years ago the strength of ecstasy tablets reduced but those now available are 3-5 times stronger than previously. Tablets containing 100-200 mg MDMA and even higher have been reported.[5] The price of ecstasy tablets has continued to increase with an average cost of £6.30 per pill in 2012 compared to £2.00 at its lowest point in 2009. This may reflect both the increased purity of ecstasy tablets and the fact that a higher proportion of pills contain MDMA.
  • Similarly, the price for MDMA powder is higher than reported in previous years.
  • 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 £39 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.[6] It is rarely injected.[7] 
  • 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.
  • After a lull, there has been a recent upsurge in availability due to increased production in Belgium and the Netherlands.[5] 

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  • A Home Office survey suggests a peak in ecstasy use in 2001 (6.8% of those aged 16- 24 years). Recent increased availability and purity do not appear to have translated into increased use, possibly because of the increased street price. In 2012 to 2013, ecstasy use among young adults fell to the lowest proportion (2.9%) since measurement began in 1996 (when the proportion was 6.6%).
  • 1.3% of people surveyed between the ages of 16-59 admitted to using it (a slight decrease from 1.4% the previous year) and it is the most commonly used drug after cannabis among those aged 16-24 years.
  • In 2012/13, approximately 434,000 doses of ecstasy were seized by the police (down 34% on 2011/12).[10] 
  • 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.[11] That said, there is emerging evidence that ecstasy is damaging to humans.[12] 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 been demonstrated in animal studies up to primate level. Research has suggested that consistent high-dose use leads to loss of presynaptic neurons, affecting the regulation of impulsivity and impairing decision making.[13] Animal studies have been criticised as being not applicable to humans but studies in humans have confirmed these findings.[12] 
  • Two cases of persistent and severe psychosis following one episode of ecstasy ingestion have been reported.[14][15] The studies reviewed by the ACMD suggested that ecstasy use did not appear significantly to affect the long-term mental health of the average user.[3] However, there is emerging evidence that ecstasy can cause mood disorders and sleep disturbance.[16] 
  • Ecstasy causes release of the neurotransmitter serotonin and inhibition of its reuptake. 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, monoamine-oxidase inhibitors), tramadol, certain opioids (including dextromethorphan 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.[13] Prospective memory (the memory of future intentions) may also be affected and this may persist long after usage has ceased.[17] 
  • 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.[18]
  • 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.[19]

Ecstasy deaths

  • There were 123 reported deaths in England and Wales between 2008-2012 related to the use of ecstasy. Deaths dropped from 44 in 2008 to 8 in 2010 but rose again to 31 in 2012.[20] One case of a death following ingestion of one tablet has been reported.[3] 
  • 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.[11]
    • Dilutional hyponatraemia - this appears to be the result of ecstasy stimulating the production of antidiuretic 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.[21] 
    • Cardiac failure - this may be due to a combination of factors, including tachycardia, hypertension and fluid retention.[22] Cardiac contractile dysfunction can also occur.[23] 
  • 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.[8] 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.[8] 
  • '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.

Further reading & references

  1. Drug penalties; GOV.UK
  2. MDMA (‘ecstasy’): A review of its harms and classification under the Misuse of Drugs Act 1971; Advisory Council on the Misuse of Drugs, 2008
  3. Government criticised over refusal to downgrade ecstasy; The Guardian, 2009
  4. Ecstasy; ecstasy.org
  5. Dangerous synthetic drugs hit the EU market; European Monitoring Centre for Drugs and Drug Addiction, 2014
  6. United Kingdom drug situation: Annual report to the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) 2013; UK Focal Point on Drugs
  7. Doward J; Ecstasy is back in clubs as newly potent drug is taken with 'legal highs', The Guardian, 2011
  8. Ecstasy; DrugScope
  9. Drug Misuse: Findings from the 2012 to 2013 Crime Survey for England and Wales; Home Office, GOV.UK
  10. Seizures of drugs in England and Wales, 2012/13; Home Office, GOV.UK
  11. Rogers G, Elston J, Garside R, et al; The harmful health effects of recreational ecstasy: a systematic review of observational evidence. Health Technol Assess. 2009 Jan;13(6):iii-iv, ix-xii, 1-315.
  12. Parrott AC; MDMA and 5-HT neurotoxicity: the empirical evidence for its adverse effects in humans - no need for translation. Br J Pharmacol. 2012 Jul;166(5):1518-20; discussion 1521-2. doi: 10.1111/j.1476-5381.2012.01941.x.
  13. Quednow BB, Kuhn KU, Hoppe C, et al; Elevated impulsivity and impaired decision-making cognition in heavy users of MDMA ("Ecstasy").; Psychopharmacology (Berl). 2006 Jan 20;:1-14.
  14. Potash MN, Gordon KA, Conrad KL; Persistent Psychosis and Medical Complications After a Single Ingestion of MDMA "Ecstasy": A Case Report and Review of the Literature. Psychiatry (Edgmont). 2009 Jul;6(7):40-4.
  15. Patel A, Moreland T, Haq F, et al; Persistent Psychosis After a Single Ingestion of "Ecstasy" (MDMA). Prim Care Companion CNS Disord. 2011;13(6). pii: PCC.11l01200. doi: 10.4088/PCC.11l01200.
  16. Ogeil RP, Rajaratnam SM, Broadbear JH; Male and female ecstasy users: differences in patterns of use, sleep quality and mental health outcomes. Drug Alcohol Depend. 2013 Sep 1;132(1-2):223-30. doi: 10.1016/j.drugalcdep.2013.02.002. Epub 2013 Feb 28.
  17. Parrott AC; Human psychobiology of MDMA or 'Ecstasy': an overview of 25 years of empirical research. Hum Psychopharmacol. 2013 Jul;28(4):289-307. doi: 10.1002/hup.2318.
  18. Martins SS, Alexandre PK; The association of ecstasy use and academic achievement among adolescents in two U.S. national surveys. Addict Behav. 2009 Jan;34(1):9-16. Epub 2008 Aug 3.
  19. Kelly BC; Mediating MDMA-related harm: preloading and post-loading among Ecstasy-using youth. J Psychoactive Drugs. 2009 Mar;41(1):19-26.
  20. Deaths Related to Drug Poisoning in England and Wales, 2012; Office for National Statistics
  21. Ghatol A, Kazory A; Ecstasy-associated acute severe hyponatremia and cerebral edema: a role for osmotic diuresis? J Emerg Med. 2012 Jun;42(6):e137-40. doi: 10.1016/j.jemermed.2009.05.001. Epub 2009 Jun 4.
  22. Irvine RJ, Keane M, Felgate P, et al; Plasma drug concentrations and physiological measures in 'dance party' participants.; Neuropsychopharmacology. 2006 Feb;31(2):424-30.
  23. Shintani-ishida K, Saka K, Yamaguchi K, et al; MDMA induces cardiac contractile dysfunction through autophagy upregulation and lysosome destabilization in rats. Biochim Biophys Acta. 2014 May;1842(5):691-700. doi: 10.1016/j.bbadis.2014.01.013. Epub 2014 Jan 31.

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.

Original Author:
Dr Laurence Knott
Current Version:
Peer Reviewer:
Dr Adrian Bonsall
Document ID:
460 (v5)
Last Checked:
23/07/2014
Next Review:
22/07/2019

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