A-Z of Drugs

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E is for Ecstasy

A decade ago Professor David Nutt published a short article in a prestigious medical journal. Although at the time he was the head of the Advisory Council on Drug Misuse in the UK, he probably imagined that his piece would never gain much notoriety or attention from the mainstream press. He was wrong about that and it ultimately cost him his job. The article was entitled “Equasy”, [sic] and in it he argued that “equine addiction syndrome” accounted for over 100 deaths in the UK each year against an average of 30 for ecstasy use. It was, of course, meant ironically as a honest attempt to put the number of deaths each year from ecstasy use in context. Horse-riding, he states, is clearly far more dangerous than popping an ‘E’. As he went on to put it in the Journal of Psychopharmacology : “This attitude raises the question of why society tolerates - indeed encourages - certain forms of potentially harmful behaviour but not others.”

The light-hearted article attracted comments from other writers and commentators. One noted that if we follow this line of argument then we should all avoid taking baths - approximately 365 Americans a year apparently drown in their own bathwater. Prof. Nutt can perhaps be reasonably criticised for trivialising the debate around ecstasy as this is an industry which has now grown to turning over €1.8 billion euros a year in Europe alone. It is also an industry that has evolved significantly. As a consequence, by products have also been produced that have also created a considerable amount of public concern.

Many people believe that MDMA (the formal chemical name for the substance) was the first purely synthetic drug to become widely available, but the base substance of the drug is actually derived from a plant. Safrole is a colourless or slightly yellow oil that is extracted from the root-bark or the fruit of Sassafra plants, usually in Cambodia. Ecstasy was first synthesized in 1912 by a chemist working for the giant pharmaceutical company Merck in Germany. Whilst he was primarily interested in developing a treatment for abnormal bleeding, it is widely believed the company put serious thought into marketing it as a slimming product. It appears that MDMA was quietly forgotten about until the 1950’s when it was allegedly used in experiments by the United States military in an attempt to produce a truth serum.

From his own personal research, Alexander Shulgin and MDMA are historically linked. Dr Shulgin gained a PhD from the University of California at Berkley before going on to work for Dow Chemicals during the early 1970’s. Whist the company was very happy with his work on insecticides they seemed less happy with his dedicated research on a range of hallucinogenic substances. As an independent researcher he has probably taken a greater range of hallucinogenic substances than anyone else in history. Among them in 1976 was MDMA. He was known to have introduced his ‘low-calorie Martini’ to many of his friends. He also remained convinced that it had a psycho-pharmaceutical use in the treatment of depression and post-traumatic stress disorder. In the early 1980s MDMA became a prescribed pharmaceutical medication by some psychiatrists to assist in the treatment of Post-Traumatic Stress Disorder (PTSD).

The main theory behind using MDMA to treat PTSD lies with a key symptom of the disorder being avoidance of emotions due to anxiety and re-traumatising. MDMA appears to reduce anxiety associated with recalling traumatic experiences allowing for increased insight and memory. Negative memories are perceived as less negative allowing for the therapist and the patient to engage in productive therapeutic sessions without the patient becoming hyper-aroused due to stress.

As other researchers became interested in MDMA for a range of medical reasons, in time it surfaced on the streets of the United States. Initially it was found in the Dallas area where it was known as ‘empathy’ due to its’ unusual trait of creating a ‘loved up’ feeling. It was not until 1985 that it was finally named as a ‘Schedule 1’ drug in the US. Use of the drug then sky-rocketed as it became an integral part of the electronic dance music craze of the late 1980’s.

Over the past decade or so, the MDMA market has undergone significant changes. The most notable of these is the emergence of ‘Molly’, or MDMA is in its crystalline / powdered form. This is normally sold loose and unlike ecstasy can also be snorted or mixed into a liquid. Ecstasy, strictly speaking, is MDMA that has various binders added before being pressed into the form of a pill or tablet. Something of an urban myth has grown up around molly; that it is ‘pure MDMA’. Whilst this is possible in theory, it is very rarely the case in practice. Despite this some users in the United States don’t recognise that molly and ecstasy are chemically identical. This has led some prevalence surveys to list them separately, and therefore inadvertently add to the myth.

Ecstasy itself has also been re-invented, to an extent. We have seen a substantial increase in the average amount of MDMA that an ecstasy tablet contains. During the 1990’s and 2000s it averaged somewhere between 50 and 80mg, but at present it is closer to 125mg. In addition ‘super pills’ or ‘super strength ecstasy’ has begun to emerge. These pills have been reported as containing up to 340mg of MDMA. It appears that this is mainly due to a form of ‘arms race’ between rival manufacturers in Holland and Belgium where the majority of the world’s supply emanates from. The potential for such higher strength pills to cause harm is clear, especially when they wind up in the hands of users who have lower tolerance levels than the more ‘hardcore’ users of the dance clubs in places like Amsterdam.

Learning from the success of headshops (of both the online and ‘brick and mortar’ variety), many manufacturers have also become more aggressive in their marketing of ecstasy. Ecstasy pills are now produced in bewildering variety of shapes, sizes and colours. Logos of companies such as Mitsubishi, Rolex, Fed Ex and Red Bull have been illegally used to help sell the product. Some pills may feature characters from movies and comics, such as the ‘Blue punisher’ or even celebrities such as Mr Donald J. Trump.

It is therefore not surprising that we have seen the re-emergence of ecstasy as a drug of major concern throughout Europe. The combination of higher-purity tablets and increasing reports of acute toxicity associated with ecstasy tablets adulterated with other substances has set alarm bells ringing.

In the short-tem MDMA / ecstasy may cause significant acute toxicity. Common effects would include agitation, nausea, bruxism (teeth-grinding), insomnia, blurred vision, increased heart rate and raised blood pressure. Seizures and arrhythmias may also occur in more acute cases. MDMA / ecstasy related deaths do as a consequence occur, with 8 such deaths in Ireland in 2016. Whilst every death is a tragedy, the number is part of the much bigger picture of 6,000 plus drug-related deaths that occur annually across Europe.

For longer term use the picture is somewhat less clear. Although MDMA / ecstasy dependence is not common, some researchers have argued that long-term effects may include damage to the central nervous system as well as neurological harms. These may include impairment of memory and some of the other higher cognitive brain functions. This may in turn lead to acute and prolonged psychosis, depressive symptoms and elevated anxiety levels. This research is ongoing, and as yet inconclusive.

The number of MDMA / ecstasy related deaths do not, as yet, appear to represent a significant new trend. Despite that the attention placed on MDMA / ecstasy by the media is likely to continue unabated. Three key factors will be important in this unfolding story : frequency of use, the number of tablets used in a session and the price.

According to the Global drugs survey, Irish consumers of ecstasy use an average of 12.5 times per year (only just short of Brazilians at 14.2 per year). They also consume 1.8 pills per session (second only to Australians) and only pay an average of €9 per pill. This equates to the 4th lowest cost in the world which may be indirectly related to consumption.

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