Ecstasy is the popular name for the synthetic psychoactive drug 3,4-methylenedioxymethamphetamine, or MDMA. It is chemically similar to methamphetamine and the hallucinogen mescaline. MDMA acts both as a stimulant and psychedelic, producing an energizing effect as well as distortions in time and perception and enhanced enjoyment from tactile experiences. MDMA exerts its primary effects in the brain on neurons that use the chemical serotonin to communicate with other neurons. The serotonin system plays an important role in regulating mood, aggression, sexual activity, sleep, and sensitivity to pain. Ecstasy has a large number of other street names. These include Adam, B-bombs, bean, Blue Nile, clarity, crystal, decadence, disco biscuit, E, essence, Eve, go, hug drug, Iboga, love drug, morning shot, pollutants, Rolls Royce, Snackies, speed for lovers, sweeties, wheels, X, and XTC.

Ecstasy is one of a group of drugs known as club drugs, because the drug is used primarily in dance clubs, at raves, and at dances on college and high school campuses. Use is more common in urban areas. Most users of ecstasy are white teenagers and young adults from middle-and upper-class households. The U.S. Office of National Drug Control Policy reports that according to the National Survey on Drug Use and Health (NSDUH), in 2010, an estimated 695,000 Americans had used MDMA in the past month (considered to be current users Page 1706  |  Top of Articleof ecstasy), with almost one million Americans using ecstasy for the first time in 2010.

Although the use of ecstasy by teenagers and young adults rose between 1996 and 2002, use appeared to decrease over subsequent years. Monitoring the Future, a study conducted every year by the University of Michigan and funded by the National Institute on Drug Abuse (NIDA), surveys middle-and high-school students on their drug use. In 2010, the survey found that 2.4% of eighth graders, 4.7% of tenth graders, and 4.5% of twelfth graders surveyed reported that they had used ecstasy at least once in the past year. In contrast, in 2002, 4.3% of eighth graders, 6.6% of tenth graders, and 10.5% of twelfth graders reported having used ecstasy.

MDMA was first synthesized in 1912 by the German pharmaceutical company Merck. Merck patented the drug in 1914. The U.S. military conducted some studies of MDMA in the 1950s, but the public knew virtually nothing about the drug until the 1970s. In the early 1970s, a few psychotherapists and psychiatrists began to explore the therapeutic uses of MDMA. They believed that they could help people benefit more from treatment if they combined doses of MDMA with psychotherapy. The number of clinicians who used MDMA as an adjunct to psychotherapy grew in the next few years.

The name “ecstasy” was coined in the early 1980s, when distributors began to envision a larger market for the drug. Ecstasy became popular as a club drug and was often sold in nightclubs and bars. Because of reports of increases in the recreational use of ecstasy and scientific reports suggesting that the related drug MDA could cause brain damage, the U.S. Drug Enforcement Administration (DEA) banned both ecstasy and 3,4-methylenedioxyamphetamine (MDA) in the mid-1980s. Following the ban on ecstasy, a lawsuit was filed against the DEA by a group of physicians who believed that ecstasy has therapeutic value. Despite the lawsuit, the DEA ban on ecstasy became permanent. As of 2018, ecstasy was classified as a Schedule I drug. Schedule I drugs are considered to have high potential for abuse and no currently accepted medical value. They are not considered safe for use even under medical supervision. It is illegal to use, sell, or manufacture ecstasy in the United States. Ecstasy that is seized by the DEA is manufactured mainly in the Netherlands, Belgium, and Canada, although some is also illegally made in laboratories in the United States.

The recreational use of ecstasy continued to increase despite the DEA ban. Through the late 1980s and 1990s, ecstasy began to be used widely at raves, which are all-night dance parties often held in warehouses and attended by large numbers of young people.

Ecstasy is sometimes described as an “entactogen,” because it gives users feelings of peacefulness, acceptance, empathy, euphoria, and closeness to others. Ecstasy is typically synthesized from such precursor chemicals as piperonyl methylketone, piperonal, isosafrole, or safrole. Safrole is an essential oil that is found in the tree Sassafras albidum, which grows in the eastern United States, and in the tree Ocotea pretiosa, which grows in South America. Safrole is also found in nutmeg, dill, parsley seed, crocus, saffron, vanilla beans, and calamus.

Some people use a product called herbal ecstasy. The main constituents of herbal ecstasy are legal herbs that are stimulants, like ephedra, guarana, and caffeine. Other herbs and vitamins may also be included. Herbal ecstasy is sold in tablet form as Cloud 9, Herbal Bliss, Ritual Spirit, Herbal X, GWM, Rave Energy, Ultimate Xphoria, and X. The quantities of ephedrine and caffeine in the tablets can vary widely. Although people who take herbal ecstasy believe it to be a legal, safe alternative to ecstasy, there are reports of numerous adverse effects, including such severe reactions as high blood pressure, seizures, heart attacks, strokes, and death.

Most users take ecstasy orally. Users also sometimes inhale or inject it. Although ecstasy is available as a capsule or a powder, it usually is sold in tablet form. The tablets are available in different colors, shapes, and sizes, and are often imprinted with logos like smiley faces, clover leaves, cartoon characters, or the logos of popular commercial brands, such as those for clothing or automobiles. On average, an ecstasy tablet has about 100 mg of MDMA. However, the MDMA content in tablets can vary a great deal. Pure MDMA salt, which is a white, bitter-tasting substance, is usually not the only ingredient in ecstasy tablets. The MDMA in ecstasy tablets is often blended with other drugs like caffeine, aspirin, dextrome-thorphan, ephedrine, methamphetamine, and MDA.

Some psychiatrists and psychotherapists still advocate the therapeutic use of ecstasy. While most of these professionals believe that recreational use of ecstasy is likely to be unsafe, they argue that small doses of unadulterated MDMA can be used effectively as an adjunct to psychotherapy when used once or twice in a controlled therapeutic setting. They believe that MDMA is beneficial because it can help patients put aside their anxiety and fear, and explore psychological issues that would Page 1707  |  Top of Articlenormally be too painful to confront. Although ecstasy-assisted psychotherapy may also be indicated in other situations, it is thought to be particularly helpful in the treatment of post-traumatic stress disorder (PTSD) and to help people with terminal illness deal with the fear of dying.

MDMA causes the release of the neurotransmitters dopamine and serotonin and the neurohormone norepinephrine. Research on the long-term effects of MDMA has mainly focused on cognition and behavioral changes related to serotonin levels.

The NIDA reports that studies provide direct evidence that chronic use of MDMA causes brain damage in humans. Using advanced brain imaging techniques, one study found that MDMA harms neurons that release serotonin (serotonin plays an important role in regulating memory and other mental functions). In a related study, researchers found that people who use MDMA heavily have memory problems that persist for at least two weeks after stopping use of the drug. Both studies strongly suggest that the extent of damage is directly related to the amount of MDMA used.

Another study, reported by the Journal of Neurology Neurosurgery and Psychiatry on April 6, 2011, supported the hypothesis that long-term users of ecstasy are at risk of brain damage. The study included a total of 17 men, 10 who were in their 20s and were long-term users of ecstasy, and seven in their 20s who had never used the drug. In a study performed by a group of Dutch researchers, magnetic resonance imaging (MRI) brain scans of the ecstasy users showed an approximate 10% shrinkage in the volume of the hippocampus (a portion of the brain responsible for the functions of learning and memory). The brain scans revealed that the ecstasy users (having taken ecstasy tablets over a six-and-a-half year period) had about 10.5% less hippocampal volume than nonusers, as well as a lower (about 4.6% on average) proportion of grey matter in the brain, suggesting that long-term effects of ecstasy may not be limited to the hippo-campus. Researchers noted as well that shrinkage of the hippocampus is already known as one finding in older patients who have such diseases associated with cognitive impairment as Alzheimer's disease.

Animal studies indicate that repeated doses of MDMA show long-term decreases in concentrations of serotonin and that ecstasy may cause long-term brain damage from severe damage to brain cells. Brain scans and psychological assessment of humans using ecstasy suggest that damage to brain cells may cause memory loss or psychological problems due to destruction of serotonin-producing neurons in the brain. In addition, damage to neurons that regulate dopamine may cause motor disturbances in humans (such as in Parkinson's disease), resulting in tremor, unsteady gait, and paralysis.

Use of MDMA produces cardiovascular effects of increased blood pressure, heart rate, and heart oxygen consumption. People with preexisting heart disease are at increased risk of cardiovascular catastrophe resulting from MDMA use. Toxicity may rise dramatically when users take multiple doses over brief periods, leading to such harmful reactions as dehydration, hyperthermia, and seizures. Long-term abuse can lead to memory loss.

MDMA tablets often contain such other drugs as ephedrine, a stimulant, and dextromethorphan, a cough suppressant with PCP-like effects at high doses. These additives increase the harmful effects of MDMA. They also appear to have toxic effects on the brain's serotonin system. In tests of learning and memory, people who use MDMA perform more poorly than people who do not use it. Research with primates shows that MDMA can cause long-lasting brain damage. Exposure to MDMA during the period of pregnancy in which the fetal brain is developing is associated with learning deficits that last into adulthood.

Like other drug use, the decision to use ecstasy results from complex combinations of factors that include genetic predisposition to risk taking, family history, stress, and peer pressure.

Ecstasy is absorbed quickly after it is taken orally, and it can be detected in the blood within about 30 minutes. It typically has its effect within 20–60 minutes after it is ingested. The average time for onset of effects is 30 minutes. It has its peak effects about 60–90 minutes after it is ingested. The main effects of ecstasy last about 3–5 hours. Women are more sensitive to ecstasy than men and are more likely to experience an optimal effect of the drug at a lower dose in proportion to body weight than men.

Ecstasy mimics the effects of the neurotransmitter serotonin, activating cell receptors in the brain that normally respond to serotonin. Serotonin is involved in many processes in the body, including the regulation of mood, aggression, sexual activity, sleep, sensitivity to pain, and eating. MDMA also causes the release of serotonin, as well as the neurotransmitters norepinephrine and dopamine. The levels of hormones like cortisol, prolactin, and testosterone increase when ecstasy is used. The level of vasopressin, a hormone that is involved in Page 1708  |  Top of Articleelevating blood pressure and retaining water in the body, also increases.

Ecstasy users report intensely pleasurable experiences after taking ecstasy. They feel euphoric and are more aware of sensory stimuli. Users often wear fluorescent jewelry or accessories and use mentholated ointments or sprays to enhance the sensory effects they experience. Users of ecstasy usually feel socially uninhibited and close to other people. They find that they have an increased sense of empathy. They also claim to become emotionally open and have exceptionally clear insight into themselves. Time perception may become distorted. Because ecstasy has a stimulant effect, users often feel energetic and can remain awake for long periods. Ecstasy increases sensuality, but it does not directly increase sexual drive or appetite. However, because it decreases inhibitions and makes users more open to others, users sometime engage in sexual activity after taking ecstasy. Men sometimes experience delayed orgasms, although orgasms may be more intense than usual.

Ecstasy users sometimes have undesirable experiences. In one research study, about 25% of users reported having gone through at least one occasion when ecstasy use resulted in unpleasant experiences and body sensations. Short-term adverse reactions that have been reported include dilated pupils, unusual sensitivity to bright light, headache, sweating, increased heart rate, tooth grinding (bruxism), spasms of the jaw muscle (trismus), loss of appetite, nausea, muscle aches, fatigue, dizziness, vertigo, thirst, numbness, tingling skin, retention of urine, staggering gait (ataxia), unsteadiness, tics, tremors, restlessness, agitation, paranoia, and nystagmus. Research has shown that driving a car under the influence of ecstasy is unsafe.

The scientific literature on the effects of ecstasy is somewhat inconsistent. This inconsistency is partly because well-controlled studies cannot be carried out on ecstasy use. However, many in the scientific community agree that brain levels of serotonin increase when ecstasy is ingested and that they decrease after an episode of ecstasy use. The depletion of serotonin is thought to cause “midweek blues.” This term refers to the lethargy, concentration and memory problems, and depressed mood that many ecstasy users experience for a few days after taking the drug. Other changes that occur for a few days after ecstasy use are increased feelings of aggressiveness, unsociability, irritability, decreased appetite, and poor sleep. Some researchers have reported that chronic heavy ecstasy use is associated with sleep disorders, depression, high levels of anxiety, impulsiveness and hostility, and problems with memory and attention. Memory and attention deficits may continue for up to 6 months after drug use is stopped, but symptoms are reported to remit after 6 to 12 months. The extent of cognitive deficits may depend on the number of tablets taken per occasion of use.

Ecstasy causes body temperature to increase. Abnormal increases in body temperature are more likely when the user is in a hot environment, such as a crowded dance floor. A number of ecstasy-related deaths have been reported that are attributable to drug-induced increases in body temperature. Several users who later died were admitted to hospitals with abnormally high temperatures, ranging from 104°F (40°C) to 109°F (43°C). The immediate cause of death in these users was damage to such organs as the liver and heart. Other deaths have occurred because of water intoxication, which can develop when ecstasy users drink too much water to combat hyperthermia. The increase in vasopressin that accompanies the Page 1709  |  Top of Articleuse of ecstasy makes excessive water intake particularly dangerous. Water intoxication results in decreased levels of sodium in the blood, which can be fatal.

Ecstasy users appear to develop tolerance to the drug with repeated use, needing more of it to achieve the effect they desire. Novice users tend to take one or two tablets per session, whereas highly experienced users may take more than three tablets per session. The use of increased doses may exacerbate the amphetamine-like effects of the drug. Heavy users sometimes binge-use, either by taking several tablets simultaneously or by repeatedly taking tablets during a single session that may last up to 48 hours. In such binging sessions, users may go without sleep or food and sometimes consume up to 20 tablets. In some cases, binge users snort powdered ecstasy or inject it. Binging on ecstasy can result in such consequences as loss of appetite, weight loss, days off from work, and depression.

Diagnosis of ecstasy use is difficult, because the effects tend to wear off after a few hours and because individuals who use ecstasy often use other drugs as well, making the effects difficult to distinguish.

There are no drug treatments for ecstasy use. Behavioral interventions have proved most successful. In cognitive-behavioral therapy, users learn to recognize, manage, and avoid situations most likely to lead to illicit drug use, and develop healthy ways to cope with stressful situations. Ecstasy is psychologically addictive in as many as 43% of users, so issues of dependency must be addressed, as must the use of other drugs in conjunction with ecstasy use.

There are scientific and political debates about whether ecstasy causes long-term damage to the human brain. Some researchers and drug enforcement agencies claim that ecstasy is a dangerous drug capable of causing irreversible brain damage, and other researchers suggest that claims of irreversible neurotoxicity in humans are exaggerated and unproven. Because of ethical considerations, ecstasy cannot be given to people who do not use it to study its effects on the brain. However, studies of brain function are sometimes carried out in people who already take ecstasy, using brain-imaging technology. These types of studies are methodologically complex, and results are interpretable in various ways. Therefore, controversy continues about the potential long-term effects of ecstasy on the human brain.

Studies conducted on rats and monkeys have shown that high doses of ecstasy can have long-term negative effects on neurons that contain serotonin. Serotonin levels become depleted in these animals, and serotonincontaining nerves become damaged. The degeneration of neurons is exacerbated when the animals are placed in high-temperature environments. In these types of studies, animals are usually given very high doses of ecstasy, and the drug is usually injected. Some researchers have argued that the results of these animal studies cannot be extrapolated to human users, who use much lower doses and typically ingest the drug orally.

Scientific research on ecstasy use has some limitations. Because ecstasy is classified as a Schedule I drug, researchers cannot easily conduct controlled experimental studies by administering MDMA to people in laboratories. Additionally, people who use ecstasy often use such other drugs as heroin, cocaine, and ketamine, either deliberately or as a result of using contaminated ecstasy. Therefore, it is difficult to determine whether effects observed in users are due to the current or previous use of these other drugs, the use of ecstasy, or the combination of ecstasy with other drugs. Scientists also cannot easily determine whether effects noted in ecstasy users are due to drug use or the personal characteristics of people who choose to use ecstasy recreationally.

Although psychiatrists and psychotherapists used ecstasy in the 1970s as an adjunct to psychotherapy, no controlled clinical trials were conducted at the time that could provide evidence for its therapeutic efficacy. After ecstasy became classified as a Schedule I drug, it became difficult for researchers to study its psychotherapeutic uses, because institutional review boards typically do not approve research studies that have the potential for causing harm to humans who participate in them.

Social networks and peer pressure play major roles in starting ecstasy use. Peer-led education about the risks of ecstasy is thought to be more effective than adult-led education programs.