MDMA (ecstasy): risks and benefits

"Ecstasy" is a common recreational drug. Chemically, it is known as MDMA, or 3,4-methylenedioxymethamphetamine. It is a type of chemically modified amphetamine compound which causes a release of serotonin and other transmitters from brain cells. It probably has a variety of other pharmacological effects.

MDMA has been shown in many studies to be neurotoxic, particularly causing harm to the cells in the brain which produce serotonin. There is evidence that MDMA can cause permanent harm or cell death. These studies have been done using rodents, monkeys, and using laboratory cell cultures. The neurotoxicity seems to be associated with, or magnified by, the increase in body temperature caused by ecstasy ingestion. Here are a few of the many references about this:
http://www.ncbi.nlm.nih.gov/pubmed/1379014
http://www.ncbi.nlm.nih.gov/pubmed/18991870
http://www.ncbi.nlm.nih.gov/pubmed/16884865
http://www.ncbi.nlm.nih.gov/pubmed/12464456

But here is a paper describing long-term MDMA exposure in monkeys, which did not lead to chemical evidence of neurotoxicity:
http://www.ncbi.nlm.nih.gov/pubmed/15039771

An important body of research is the Netherlands XTC Toxicity (NeXT) study. This 2008 paper from the NeXT study describes a prospective follow-up of new low-dose ecstasy users, and found evidence through functional brain imaging of neurotoxicity in the ecstasy-using group:
http://www.ncbi.nlm.nih.gov/pubmed/18842607

Here is another similar 2007 paper published in Archives of General Psychiatry describing a slight reduction in verbal memory performance in individuals who had used even just a few doses of ecstasy, compared to individuals who had not used any:
http://www.ncbi.nlm.nih.gov/pubmed/17548754

However, this paper gave rise to a good debate in subsequent issues of this journal. Basically, neither group in the study declined in memory performance, it's just that the non-ecstasy group improved more than the ecstasy group on re-testing. The ecstasy group included some people who had used much more than others. Also, the ecstasy-using group may have been more anxious about negative memory effects, since they had been warned about this possibility in advance. Such anxiety can impare test performance. The ecstasy-using group may have taken drugs tainted with impurities. A very important point I would add is that most people who use ecstasy recreationally do so in a chaotic, loud environment such as a rave--the drug may act as an emotional or interpersonal "amplifier", which in the case of a rave, could give rise to an amplification of social chaos. Also such an environment might lead to a higher degree of hyperthermia, which is associated with worse neurotoxicity. Use of ecstasy in a controlled, gentle, intimate environment might be much safer.


Here's a reference to a 2009 British Journal of Psychiatry study showing no difference in serotonin transporter binding between groups of former MDMA users, other drug users, and controls with no history of street drug use:
http://www.ncbi.nlm.nih.gov/pubmed/19336788?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum


This is a randomized, double-blind study looking at physical and emotional effects of acute MDMA ingestion, at low (1 mg/kg) and high (1.6 mg/kg) doses. It did not demonstrate hyperthermia as an effect of the drug, rather it implies that hyperthermia is caused by the environmental situation in conjunction with the drug (e.g. vigorous activity dancing indoors in a crowd).
http://www.ncbi.nlm.nih.gov/pubmed/18626271

There may be therapeutic applications for MDMA. The subjective effects of the drug can be to dramatically increase a feeling of openness, empathy or connectedness with other people, both on an emotional level and also sensually or physically.

Here are some references about this:
http://www.ncbi.nlm.nih.gov/pubmed/19273493
{this is a brief 2009 review of the subject of possible psychotherapeutic uses of MDMA, such as in anxiety disorders and PTSD}

http://www.ncbi.nlm.nih.gov/pubmed/19004414
{this 2008 study from Madrid showed that 50-75 mg doses of MDMA used in conjunction with psychotherapy for PTSD appeared to be physiologically and emotionally safe for 6 subjects. The study apparently had to be ended due to political pressures, before more subjects could be treated. Clearly, this is a controversial issue}

A psychiatrist by the name of Michael Mithoefer is trying to do research about using MDMA for treating PTSD. Here are some related sites:
http://scienceblogs.com/neurophilosophy/2007/11/mdma_for_ptsd.php
http://www.maps.org/mdma/protocol/
http://www.maps.org/mdma/

I think it is important to be open-minded about things outside the mainstream, and to recognize that mainstream research may sometimes dismiss ideas considered too controversial. Yet I recognize that the above sites have a biased agenda of their own which may undervalue important risk analyses published in the mainstream literature.

Answering questions relating to controversial issues, such as the potential use of MDMA as a therapeutic agent, requires a very neutral, unbiased research environment.

Aside from therapeutic possibilities in PTSD, it seems to me that MDMA might be worth investigating as an adjunct for couples' therapy, particularly for couples who feel inhibited or disconnected with each other. MDMA can foster a sense of connectedness, sensuality, and empathy. These three domains are often major weaknesses in troubled relationships. Apparently MDMA has been used in relationship therapy in the past, but the results have been poorly documented.

I have seen patients for whom MDMA use appears to have been part of a destructive long-term drug abuse pattern, which has most likely exacerbated mood, anxiety, and interpersonal problems. I have also seen a few patients for whom isolated experiences with MDMA have led to strong, memorable experiences of openness and intimacy with friends or partners.

In conclusion, I emphasize that MDMA is clearly a dangerous drug. It is most definitely neurotoxic. The risk of neurotoxicity is most likely higher with frequent, regular, or long-term use. Most "ecstasy" obtained on the street is tainted with numerous impurities--both deliberately, to reduce production costs, and as by-products of crude synthetic techniques; the impurities are likely to add to potential toxicity. I think that the setting in which MDMA is used most frequently (e.g. as a "dance drug") is likely to magnify its toxicity, in that hyperthermia is more likely, and any intimate emotional benefit is less likely. Many MDMA users are taking this drug frequently, over a period of years--I think this pattern has a very high risk of causing permanent neuropsychiatric harm.

We do not know yet if MDMA could have a positive therapeutic role for some people, but if it did, it would most likely have to be used only a very small number of times, in a carefully controlled, socially supported, comfortable, quiet, cool setting, by individuals who are already in a state of relative emotional calm. I suspect that a history of psychotic or bipolar illness, or a history of other street drug use or dependence, would greatly magnify the psychiatric risks of MDMA use. In the meantime, the existing research shows that any possible benefits would have to be weighed against very substantial risks. It remains an illegal drug in most jurisdictions.