Party drug- MDMA (Ecstasy)

3,4-methylenedioxy-methamphetamine (MDMA) is a synthetic drug that alters mood and perception. ‘Ecstasy’ or ‘Molly’ (MDMA) was the archetypical dance drug (used in the dance, music/rave) inducing both stimulant and empathogenic effects.

The use of this drug is now no longer confined to the dance floor. It is being used commonly at house parties or other more intimate social gatherings.

Preparations, Purity and Routes of use:

MDMA was first synthesized in 1912 by Merck Pharmaceuticals (a drug whose chemical structure is modified to avoid being included within a list of drugs prohibited by legislation).

MDMA is most commonly taken orally though it may be snorted or injected. MDMA is commonly sold as tablets, with different tablets being identified by an imprinted logo (for example of a cartoon character, car manufacturer or animal), but may also be found as capsules or powder. The average dose of an ecstasy tablet containing MDMA is about 70 mg (range 50–150 mg).

Ecstasy tablets were often found to contain substances other than MDMA. These included analogues of MDMA, such as methylenedioxyamphetamine (MDEA), N-methyl-1-(1,3-benzo-dioxol-5-yl)-2-butanamine (MBDB), and methylenedioxyethyl- amphetamine (MDEA) or combinations of stimulants such as ephedrine or amphetamine and hallucinogens such as LSD or ketamine.

Prevalence and patterns of ecstasy use:

The typical pattern of use is one to four tablets a night. Regular users will use between once or twice a week to once every fortnight, though many users will often consume larger number of tablets (20 or 30) over a single session.

Ecstasy is rarely taken in isolation and polydrug use is the norm, with different adjunctive substances taken at different times over the course of a night. For example,

👉Alcohol is taken with ecstasy at the beginning of the night party to get a stronger/better high.

👉Cocaine & amphetamines are taken to maintain arousal and a state of alertness (the MDMA enactogenic effects fade away in 2–4 hrs).

👉Finally depressants such as cannabis, alcohol, benzodiazepines and opiates may be taken in the last part of the night to calm down before going home since the untoward after-effects of ecstasy (irritability, insomnia, and restlessness) may persist well beyond its ‘pleasurable’ effects.

With a chronic high dosage, ecstasy users develop tolerance and experience a decrease in the desired effects over time, which could lead to exploration of use of other stimulants and hallucinogens.

Physical effects and complications:

👉 Tachycardia, increased respiratory rate, increased BP, increased motor activity, tremor, mydriasis, increased temperature, anorexia and sweating.

👉 Nausea, vomiting, diarrhoea, Jaw tightening (bruxism), xerostomia, teeth grinding with molar erosion may also be seen.

👉 Arrhythmias, metabolic acidosis, cerebral haemorrhages, convulsions, coma, rhabdomyolysis, thrombocytopenia, disseminated intravascular coagulation, SIADH, acute kidney failure, acute liver failure and malignant hyperthermia.

👉 MDMA is a potentially damaging cardiac stimulant;  may possibly lead to a fenfluramine-like valvular heart disease condition.

👉 Dehydration is common and thirsty clubbers replace body fluids lost during sweating sensibly with fruit juices or less sensibly but quite commonly with alcohol. Very rarely excessive intake of hypotonic fluids, coupled with an increase in vasopressin levels, has led to the occurrence of lethal hyponatraemia. Deaths as a result of SIADH are very rare but can be fatal, potentially impairing judgement or stimulating repetitive compulsive behaviours.

👉 In most cases, users of ecstasy develop a mild serotonin syndrome ( Confusion, restlessness, headache, nausea, vomiting, increased heart rate and BP, tremors, shivering, sweating) after acute drug intake.

SSRIs taken acutely after MDMA (taken by users to intensify the ecstasy effects) may increase the risk of precipitating a serotoninergic syndrome.

Psychological effects:

👉 Enhanced mood, increased energy, openness, heightened sensory perception, and mild perception alterations.

👉 Altered state of consciousness with emotional and sensual overtones ( a profound feeling of attachment and connection).

👉 Acute episodes of anxiety, panic, paranoia, prolonged depersonalization, brief psychotic episodes, flashbacks, and even craving for chocolate.

👉 Many users of MDMA report ‘midweek blues’, with some individuals reporting clinically borderline levels of depression in the days following MDMA which could reflect depletion of serotonin following the acute elevation that follows ingestion of MDMA.

👉 Deficit in verbal memory under both immediate and delayed recall conditions. Deficits in other areas of cognitive function, such as verbal fluency, executive function, impulse control, reaction time, and processing speed have been reported as well. MDMA use may be associated with longer visual scanning times, reaction times, or planning times.

Neurotoxicity:

MDMA is generally considered to be a selective 5-HT neurotoxin. After administration of MDMA, animals have reduced levels of 5-HT, 5-hydroxyindole acetic acid, and tryptophan hydroxylase.

Management:

Cognitive Behaviour Therapy may be helpful in quitting the drug as well as treating any coexisting anxiety/ depressive disorders.

Antidepressant treatments should not be given until 2–4 weeks after cessation of MDMA use before assessment and confirmation of any disorder. 

Sometimes, treatment is important at early stage since being depressed is associated with an enhanced initial response to stimulant drugs and higher relapse risk.

If you have any questions or concerns, please write in the comment box…

Reference:

  • New Oxford Textbook of Psychiatry(2nd edition).

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