MDMA


3,4-Methylenedioxymethamphetamine, commonly known as ecstasy, and molly, is an entactogen with stimulant and minor psychedelic properties.
MDMA was first synthesized in 1912 by Merck chemist Anton Köllisch. It was used to enhance psychotherapy beginning in the 1970s and became popular as a street drug in the 1980s. MDMA is commonly associated with dance parties, raves, and electronic dance music. Tablets sold as ecstasy may be mixed with other substances such as ephedrine, amphetamine, and methamphetamine. In 2016, about 21 million people between the ages of 15 and 64 used ecstasy. In the United States, as of 2017, about 7% of people have used MDMA at some point in their lives and 0.9% have used it in the last year. The lethal risk from one dose of MDMA is estimated to be from 1 death in 20,000 instances to 1 death in 50,000 instances.
The purported pharmacological effects that may be prosocial include altered sensations, increased energy, empathy, and pleasure. When taken by mouth, effects begin in 30 to 45 minutes and last three to six hours. Short-term adverse effects include grinding of the teeth, blurred vision, sweating, and a rapid heartbeat, and extended use can also lead to addiction, memory problems, paranoia, and difficulty sleeping. Deaths have been reported due to increased body temperature and dehydration. MDMA acts primarily by increasing the release of the neurotransmitters serotonin, dopamine, and norepinephrine in parts of the brain. It belongs to the substituted amphetamine classes of drugs. MDMA is structurally similar to mescaline, methamphetamine, as well as endogenous monoamine neurotransmitters such as serotonin, norepinephrine, and dopamine.
MDMA has limited approved medical uses in a small number of countries, but is illegal in most jurisdictions. MDMA-assisted psychotherapy is a promising and generally safe treatment for post-traumatic stress disorder when administered in controlled therapeutic settings. In the United States, the Food and Drug Administration has given MDMA breakthrough therapy status. Canada has allowed limited distribution of MDMA upon application to and approval by Health Canada. In Australia, it may be prescribed in the treatment of PTSD by specifically authorised psychiatrists.

Uses

Recreational

MDMA is often considered the drug of choice within the rave culture and is also used at clubs, festivals, and house parties. In the rave environment, the sensory effects of music and lighting are often highly synergistic with the drug. The psychedelic amphetamine quality of MDMA offers multiple appealing aspects to users in the rave setting. Some users enjoy the feeling of mass communion from the inhibition-reducing effects of the drug, while others use it as party fuel because of the drug's stimulatory effects. MDMA is used less often than other stimulants, typically less than once per week.
MDMA is sometimes taken in conjunction with other psychoactive drugs such as LSD, psilocybin mushrooms, 2C-B, and ketamine. The combination with LSD is called "candy-flipping". The combination with 2C-B is called "nexus flipping". For this combination, most people take the MDMA first, wait until the peak is over, and then take the 2C-B.
MDMA is often co-administered with alcohol, methamphetamine, and prescription drugs such as SSRIs with which MDMA has several drug-drug interactions. Three life-threatening reports of MDMA co-administration with ritonavir have been reported; with ritonavir having severe and dangerous drug-drug interactions with a wide range of both psychoactive, anti-psychotic, and non-psychoactive drugs.

Medical

As of 2023, MDMA therapies have only been approved for research purposes, with no widely accepted medical indications, although this varies by jurisdiction. Before it was widely banned, it saw limited use in psychotherapy. In 2017 the United States Food and Drug Administration granted breakthrough therapy designation for MDMA-assisted psychotherapy for post-traumatic stress disorder.
Some researchers have proposed that psychedelics in general may act as active "super placebos" used for therapeutic purposes.

Others

Small doses of MDMA are used by some religious practitioners as an entheogen to enhance prayer or meditation. MDMA has been used as an adjunct to New Age spiritual practices.

Forms

MDMA has become widely known as ecstasy, usually referring to its tablet form, although this term may also include the presence of possible adulterants or diluents. The UK term "mandy" and the US term "molly" colloquially refer to MDMA in a crystalline powder form that is thought to be free of adulterants. MDMA is also sold in the form of the hydrochloride salt, either as loose crystals or in gelcaps. MDMA tablets can sometimes be found in a shaped form that may depict characters from popular culture. These are sometimes collectively referred to as "fun tablets".
Partly due to the global supply shortage of sassafras oil—a problem largely assuaged by use of improved or alternative modern methods of synthesis—the purity of substances sold as molly have been found to vary widely. Some of these substances contain methylone, ethylone, MDPV, mephedrone, or any other of the group of compounds commonly known as bath salts, in addition to, or in place of, MDMA. Powdered MDMA ranges from pure MDMA to crushed tablets with 30–40% purity. MDMA tablets typically have low purity due to bulking agents that are added to dilute the drug and increase profits and binding agents. Tablets sold as ecstasy sometimes contain 3,4-methylenedioxyamphetamine, 3,4-methylenedioxyethylamphetamine, other amphetamine derivatives, caffeine, opiates, or painkillers. Some tablets contain little or no MDMA. The proportion of seized ecstasy tablets with MDMA-like impurities has varied annually and by country. The average content of MDMA in a preparation is 70 to 120mg with the purity having increased since the 1990s.
MDMA is usually consumed by mouth. It is also sometimes snorted.

Effects

In general, MDMA users report feeling the onset of subjective effects within 30 to 60 minutes of oral consumption and reaching peak effect at 75 to 120 minutes, which then plateaus for about 3.5 hours. The desired short-term psychoactive effects of MDMA have been reported to include:
  • Euphoria – a sense of general well-being and happiness
  • Increased self-confidence, sociability, and perception of facilitated communication
  • Entactogenic effects—increased empathy or feelings of closeness with others and oneself
  • Dilated pupils
  • Relaxation and reduced anxiety
  • Increased emotionality
  • A sense of inner peace
  • Mild hallucination
  • Enhanced sensation, perception, or sexuality
  • Altered sense of time
The experience elicited by MDMA depends on the dose, setting, and user. The variability of the induced altered state is lower compared to other psychedelics. For example, MDMA used at parties is associated with high motor activity, reduced sense of identity, and poor awareness of surroundings. Use of MDMA individually or in small groups in a quiet environment and when concentrating, is associated with increased lucidity, concentration, sensitivity to aesthetic aspects of the environment, enhanced awareness of emotions, and improved capability of communication. In psychotherapeutic settings, MDMA effects have been characterized by infantile ideas, mood lability, and memories and moods connected with childhood experiences.
MDMA has been described as an "empathogenic" drug because of its empathy-producing effects. Results of several studies show the effects of increased empathy with others. When testing MDMA for medium and high doses, it showed increased hedonic and arousal continuum. The effect of MDMA increasing sociability is consistent, while its effects on empathy have been more mixed.

Side effects

Short-term

Acute adverse effects are usually the result of high or multiple doses, although single dose toxicity can occur in susceptible individuals. The most serious short-term physical health risks of MDMA are hyperthermia and dehydration. Cases of life-threatening or fatal hyponatremia have developed in MDMA users attempting to prevent dehydration by consuming excessive amounts of water without replenishing electrolytes.
The immediate adverse effects of MDMA use can include:
Other adverse effects that may occur or persist for up to a week following cessation of moderate MDMA use include:
; Physiological
;Psychological
  • Anhedonia
  • Anxiety or paranoia
  • Depression
  • Impulsiveness
  • Irritability
  • Memory impairment
  • Restlessness

    Long-term

, the long-term effects of MDMA on human brain structure and function have not been fully determined. However, there is consistent evidence of structural and functional deficits in MDMA users with high lifetime exposure. These structural or functional changes appear to be dose dependent and may be less prominent in MDMA users with only a moderate lifetime exposure. Nonetheless, moderate MDMA use may still be neurotoxic and what constitutes moderate use is not clearly established.
Furthermore, it is not clear yet whether "typical" recreational users of MDMA will develop neurotoxic brain lesions. Long-term exposure to MDMA in humans has been shown to produce marked neurodegeneration in striatal, hippocampal, prefrontal, and occipital serotonergic axon terminals. Neurotoxic damage to serotonergic axon terminals has been shown to persist for more than two years. Elevations in brain temperature from MDMA use are positively correlated with MDMA-induced neurotoxicity. However, most studies on MDMA and serotonergic neurotoxicity in humans focus more on heavy users who consume as much as seven times or more the amount that most users report taking. The evidence for the presence of serotonergic neurotoxicity in casual users who take lower doses less frequently is not conclusive.
However, adverse neuroplastic changes to brain microvasculature and white matter have been observed to occur in humans using low doses of MDMA. Reduced gray matter density in certain brain structures has also been noted in human MDMA users. Global reductions in gray matter volume, thinning of the parietal and orbitofrontal cortices, and decreased hippocampal activity have been observed in long term users. The effects established so far for recreational use of ecstasy lie in the range of moderate to severe effects for serotonin transporter reduction.
Impairments in multiple aspects of cognition, including attention, learning, memory, visual processing, and sleep, have been found in regular MDMA users. The magnitude of these impairments is correlated with lifetime MDMA usage and are partially reversible with abstinence. Several forms of memory are impaired by chronic ecstasy use; however, the effects for memory impairments in ecstasy users are generally small overall. MDMA use is also associated with increased impulsivity and depression.
Serotonin depletion following MDMA use can cause depression in subsequent days. In some cases, depressive symptoms persist for longer periods. Some studies indicate repeated recreational use of ecstasy is associated with depression and anxiety, even after quitting the drug. Depression is one of the main reasons for cessation of use.
At high doses, MDMA induces a neuroimmune response that, through several mechanisms, increases the permeability of the blood–brain barrier, thereby making the brain more susceptible to environmental toxins and pathogens. In addition, MDMA has immunosuppressive effects in the peripheral nervous system and pro-inflammatory effects in the central nervous system.
MDMA may increase the risk of cardiac valvulopathy in heavy or long-term users due to activation of serotonin 5-HT2B receptors. MDMA induces cardiac epigenetic changes in DNA methylation, particularly hypermethylation changes.