NDARC Monograph 62 (2010)

INTRODUCTION

MDMA under the name of ”ecstasy” was first noted in the nightclub scene in the 1980s in the UK, US, Europe, and Australia in the late 1980s and early 1990s 1 2. For the first decade of use when the prevalence of use was low, MDMA was regarded as a relatively benign “party drug”. This perception gradually changed for a number of reasons.

First, in the mid-1990s, there were some widely publicised deaths attributed to ecstasy use in Australia and the UK3. One case in Australia in particular received huge media attention (that of Anna Wood). An attractive young girl from a middle-class family in Sydney died after taking MDMA and the girl’s parents became very active in efforts to promote awareness of the risks of ecstasy’s use.

Second, in 2002, a study funded by the United States National Institute on Drug Abuse (NIDA) was published in Science that reported apparently devastating effects of “recreational” levels of MDMA on serotonergic neurons in the brains of monkeys4. This study was very heavily promoted, and led to understandable concerns in the community about impacts that using this drug would have upon the brains of the millions of young adults. The study was later retracted following the discovery that the monkeys had in fact been mistakenly given a different drug (methamphetamine). The retraction5 received much less community attention than the original study.

Third, a number of studies have found that regular ecstasy use was associated with subtle impairments in cognitive functioning such as verbal memory. These studies typically compared ecstasy users with non-users on standardised psychological tests of cognitive functioning, and found that ecstasy users performed less well on some tests than non-users.

This monograph arose out of the need for a synthetic review of the existing evidence on the epidemiology of “ecstasy” (MDMA) use and its putative adverse health and psychological consequences.

In assessing the adverse effects of using any drug we must first consider whether an association exists between using the drug and the adverse health outcome of interest. Then, we must examine alternative explanations for the association, that is, generate a list of other factors might explain the relationship and generate evidence to exclude them. We must also attempt to estimate the magnitude of any increase in risk that users have of experiencing that outcome. All of these steps require studies that have used appropriate methodological designs.

In this monograph, a number of possible consequences of ecstasy use are considered. In each chapter, evidence on the association between ecstasy and the outcome of interest is presented, with critical evaluation of the evidence that can be brought to bear on the nature of the relationship.

The logic underlying this monograph is similar to that of the monographs on The health and psychological consequences of cannabis use written by Hall and colleagues in 19946 and updated in 20017. The guiding principles underlying an examination of the evidence on the effects of ecstasy are outlined by Hall in Chapter 2.

Chapter 3 provides a very brief overview of the history of use of MDMA and a summary of the characteristics of the illicit “ecstasy” market. As will be clear from that Chapter, some of those characteristics (e.g. lack of quality control over production) make it more difficult to infer whether “ecstasy” is causally related to the adverse health outcomes of interest; whether MDMA is involved in those outcomes; and how much of the associations may also reflect other factors. Evidence on the epidemiology of ecstasy use in Australia and elsewhere is discussed in Chapter 4.

In Chapter 5, Iain McGregor, Murray Thompson and Paul Callaghan review research on the psychopharmacology of MDMA. This evidence is drawn largely from carefully conducted laboratory studies with both animal and humans. It provides a reasonable degree of confidence in our understanding of the acute effects of the drug on the brain and behaviour.

The acute adverse health effects of ecstasy (MDMA) use are reviewed by Edmund Silins in Chapter 6. The possibility that MDMA has effects upon the reproductive and immunological systems is reviewed by Ross Beck in Chapter 7.

Chapter 8, with contributions from Libby Topp and Raimondo Bruno, reviews the animal and human evidence that can be brought to bear on the question of whether ecstasy (MDMA) users can develop dependence on the drug. Chapter 9 reviews the evidence on the association between ecstasy use, other drug use and mental health problems. Edmund Silins and Richard Mattick review evidence on the possible cognitive effects of ecstasy (MDMA) use in Chapter 10. Edmund SiIins also reviews the mechanisms of ecstasy-related mortality in Chapter 11, including the evidence on the magnitude of risk for mortality related to this drug.

In Chapter 12, Natasha Sindicich and colleagues summarise the literature on the putative therapeutic uses of MDMA for the treatment of psychological disorders.

As will become clear, the state of the evidence in many areas has not yet moved beyond documenting associations between MDMA use and adverse outcomes.

This monograph therefore identifies what research needs to be done to more definitively answer questions about whether ecstasy has adverse effects on health of type reviewed. These suggestions are provided in Chapter 13.