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E for Ecstasy
by Nicholas Saunders

[ References 1-50 ] [ Index ] [ References 101-150 ]

Appendix 1: Reference Section (51-100)
51 Toxicity and deaths from MDMA from The Lancet by John Henry et al. August 1992

A report of toxicity and fatalities related to MDMA use picked up through a search of enquirers to the National Poisons Information Service in London and encountered directly by doctors at the National Poisons Unit at Guy's Hospital, London during 1990 and 1991.

There was a striking increase in the number of calls to the NPIS related to Ecstasy use. What was being sold as E usually contained MDMA but MDA and amphetamine were also found; mixtures were uncommon. Henry et al. say that co-ingeston of MDA with MDMA cannot be excluded by analysis of biological samples and that the pattern of toxicity did not seem to be a result of overdose. One analytically documented overdose showing plasma MDMA 7.72fmg/l - allegedly 42 tablets - resulted only in a "hangover" with tachycardia and hypertension.

Reports from the USA suggested MDMA was only mildly toxic. The main cause of death was cardiac arrhythmias; rhabdomyolysis and disseminated intravascular coagulation (DIC). Most cases the authors were consulted about had mild symptoms. There was a clear pattern of toxicity in the most severe cases. Death was probably due to heatstroke "in which severe hypothermia was accompanied by DIC". There was no evidence of drug impurity being responsible for toxicity. All fatalities occurred after the user had been at a crowded party or club. Sustained physical activity, high ambient temp, inadequate fluid replacement could all reduce heat loss and the direct effect of the drug may upset the thermoregulatory mechanism. The authors conclude that MDMA is capable of causing severe toxicity and that the pattern of acute toxicity witnessed in the series of cases studied may be due mainly to the circumstances in which it is misused.

52 Numbers of Ecstasy-related deaths between January 1988 and July 1992, held by the National Poisons Unit at Guy's Hospital on 8 March 1993

The deaths include those reported directly to the NPU by doctors seeking advice and those picked up by the unit from press reports. The list is not comprehensive. In particular, as knowledge of symptoms related to Ecstasy-use spreads among the medical community, doctors make fewer queries to the NPU. Ecstasy-related deaths are held to be confirmed if any amount of the drug is found in the patient's blood or urine during treatment or in a postmortem. In all the deaths picked up by the NPU, the level of MDMA present was very low. Unconfirmed deaths are those in which the patient or others have reported recent drug use verbally but no blood or urine sample has been taken.

From January 1988 to July 1992, there were 14 confirmed deaths, of which 13 resulted from overheating and one from asthma, and 4 unconfirmed deaths, including one from liver failure and one stroke.

Of these, 2 confirmed deaths occurred in 1988; 2 confirmed deaths and one unconfirmed death occurred in 1989; 7 confirmed deaths and one unconfirmed death occurred in 1991; and 2 confirmed and two unconfirmed deaths occurred in 1992.

In 1992 there was also one confirmed death related to MDA and one confirmed death related to MDEA.

53 A report of five deaths associated with the use of MDEA and MDMA, by Dr. G. Dowling, Journal of the American Medical Association, 1987

Three of the subjects had known medical problems before taking the drug, while one was killed by an electric shock apparently after having climbed a pylon. Two had preexisting heart conditions and one had asthma. MDMA was thought not to have been the primary cause of death in four of these cases, although it is suggested that people with cardiac diseases may be predisposed to sudden death by taking MDMA. The fifth death was not explained by other medical factors, but there was no evidence that it was due to taking MDMA.

54 Conversation with Dr. Les King, team leader of the drugs intelligence laboratory at the Forensic Science Laboratory at Aldermaston, part of the Forensic Science Service, a Government agency, 14/12/92

The drugs intelligence laboratory analyses suspected drugs sent by the police, that have been seized from people arrested on suspicion of being in the possession of controlled drugs. Dr. King points out that samples sent to the lab are not necessarily representative of what is being sold on the streets. No statistical analysis of samples is done at Aldermaston, but Dr. King related his impression of the overall pattern of findings, based on personal experience. The lab is not usually told what drug to look for and therefore runs a series of tests to see whether any controlled drug is present.

Impurities are not looked for. But the typical weight of a tablet sent to the lab is from 200 to 600 mg, so non-psychoactive filler is nearly always used. Dr. King has not come across or heard of poisonous substances present in samples of Ecstasy.

Nearly all samples are in the form of capsules and tablets. The lab consistently finds that about 90% contain an active ingredient, while the rest are fake.

When tablets contain MDMA, MDA and MDEA, there is not normally any other drug present. Typically, tablets or capsules contain about 100 mg MDMA or 60-70 mg MDA. Doses vary by 10-20% above or below this amount according to the 'brand' of tablet or capsule, but each brand is fairly consistent from one pill to the next. Recently, a lot of MDEA has been seen but not enough to establish a figure for a typical dose.

The trend in 1991 and 1992 was an increase in MDA but this has peaked and MDMA, MDA and MDEA are now found in roughly equal proportions. MDEA is still on the increase.

There has been a tendency over the years towards dilution of doses - a typical Ecstasy tablet today probably contains some 10-20% less MDMA than it would have contained a few years ago.

Each brand of Ecstasy isaround for 3 to 6 months. Dr. King says this short brand lifespan may be due to fake lookalikes giving the brand a bad name. Tablets composed of amphetamine-based concoctions may be sold as Ecstasy, when MDMA is in short supply. However, these are also sold under other names.

In the past year there has been a trend towards "amphetamine cocktails". One contained amphetamine and LSD, complete with ground-up paper (presumably the 'blotter' LSD is usually supplied on). Another, believed to be sold under the name "banana split", contained amphetamine, cocaine and LSD. Another recent cocktail is amphetamine and Tiletamine. Tiletamine is a vetinerary anaesthetic similar to Ketamine and is manufactured in England for export only. A few kilos were stolen but the source has now been cut off.

A reagent, known as Marquis, consists of sulphuric acid and formaldehyde. It turns orange when mixed with amphetamines and shows a black/purple colour when combined with MDA, MDMA and MDEA. However, it also turns black with various prescription drugs and even paper, so cannot be reliably used to test drug samples. [Someone doing such tests "day in day out" may build up enough experience to distinguish between the colour changes in Marquis when it is combined with MDA, MDMA and MDEA - various shades of brown and orange - but inexperienced users could not hope to do so.] Marquis does however serve as a fairly reliable test for opiates, which show purple.

55 Medicine Now, 9/3/92, BBC Radio 4

Alan Matthews, former editor of International Journal on Drug Policy, spoke on this radio programme. He said that Ecstasy allows people to examine areas that would normally result in pain or distress with a sense of detachment. It does all this without any loss of control or contact with reality. . . For these reasons it is used as an adjunct to psychotherapy, this gives us some insights into its enormous popularity at the moment . . . almost a spiritual experience. It drops the kind of emotional barriers that we all have built into our lives to cope with society and relationships and life in general. It seems to lower those barriers so that people feel more outgoing. In a sense it dissolves the individual into a wider group experience. If you've taken the drug in a club with a thousand other people who are also on the same level, it really does give a very powerful group experience.

Matthews also said that Ecstasy may cause minor psychological problems. Figures on deaths due to Ecstasy were never easy to unravel. Ecstasy may have been used in combination with other drugs; or there may be problems related to the setting - a very hot, overcrowded club with no drinking water may lead to dehydration, heat exhaustion or heatstroke. Taking Ecstasy in combination with another drug and being in such a club could lead to a serious situation. But taking Ecstasy is not the worst thing people can do. "The worst thing they could do actually is go out and drink alcohol and dance for eight hours; that would definitely kill them."

56 Phone conversation with Dr. Russell Newcombe, lecturer in social policy and social work at Manchester University, 19/2/93

Dr. Newcombe had read a couple of articles about people who have died of heatstroke where mention has been made that the victims used to get high temperatures as children. This could be a clue as to why some people are vulnerable to overheating.

Dr. Newcombe took part in a survey of clubs playing rave music in the North West in 1992 and estimates that there were about 30,000 people attending at weekends. He estimates that the proportion of people using E varied from 50% to 90% depending on the club.

57 Effects of MDMA on Autonomic Thermoregulatory Responses of the Rat, by Christopher Gordon et al., 1990

Rats were observed at ambient temperatures of 10 degrees , 20 degrees and 30 degrees C. Measurements were made of their metabolic rate, evaporative water loss [equivalent to sweating, but rats lick their fur instead], hyperthermia, hypothermia, motor activity, skin temperature, heart rate and 'lethality'. Each rat was measured after being administered plain saline and also after 30 mg/kg MDMA in saline. The following results occurred when the rats were given MDMA but not when they were given plain saline: (1) The rats lost water through evaporation far more rapidly at 30 degrees ; (2) They increased their metabolic rate and maintained a higher ambient temperature instead of attempting to reduce their temperature; (3) They maintained the same activity instead of reducing it when the temperature rose; (4) They showed a sharp rise in body temperature instead of a fall in temperature at 30 degrees and a fall instead of rise in temperature at 10 degrees and (5) They increased their heart rates by varying amounts at 30 degrees . At the high temperature, the rats' core body temperature increased rapidly before they died. Rats' tail temperature did not increase. [Raising tail temperature is their normal way of getting rid of heat.] The cause of death was not examined but appeared consistent with overheating.

The mechanism of the effect was not studied but the changes in body temperature were presumed to be affected by the level of serotonin present in parts of the brain, which is altered by MDMA.

I spoke to Dr. Gordon on the phone and learned that he is a specialist in temperature control mechanisms. MDMA is one of the most effective compounds he has tried for making animals lose control of their body temperature. They actually seemed to prefer hot ambient temperatures when they were already too hot, although this had not yet been tested. Although MDMA inhibits heat loss in rats through their tails, they do "drool all over the place" trying to keep cool.

Dr. Gordon has made a long chamber 1 foot in diameter with one end kept hot and the other cool. Animals can be put inside so they can choose whatever ambient temperature they prefer.

58 Notes from meeting with Dr. John Merrill of NW Regional Health Authority

Dr. Merrill answers some of the most frequently raised queries about Ecstasy:

Allergic reactions: none are known.

Asthma: There is no pharmacological reason why asthma should be made any worse by E.

Diabetes: There is no known effect on blood sugar, but if you take E you are likely to be more energetic. If you are diabetic, you should adjust your sugar intake or insulin dose to allow for increased physical activity.

Epilepsy: E can cause epileptic fits if taken in overdose. If you suffer from epilepsy and take E you are more likely to have fits.

Liver problems: Recently several cases of jaundice have been reported in those who take E. Many of these have been very serious, leading to irreversible liver failure, liver transplantation or death. Its not clear why this happens. It may be that E is only toxic to the liver after many doses over many months. Or the liver failures could be due to toxic by products in poorly manufactured E.

Pregnancy: All drugs are potentially toxic to a developing foetus, and the younger it is the more dangerous they are. There are good reasons to believe that E may cause congenital abnormalities. It could cause miscarriage later in pregnancy. If you are pregnant, don't even consider taking E. [Experiments with animals show no damage.108]

Dr. Merrill added in conversation that people with hay fever and eczema who take E may also face higher risks.

59 MDMA - The Dark Side of Ecstasy, by Gregory Hayner and Howard McKinney, from Journal of Psychoactive Drugs, Vol. 18/4 1986

This paper concerns toxic effects of MDMA on illicit users who attended the Haight Ashbury Free Medical Clinic in 1986.

The authors note that both the doses taken and user's reactions were variable. Analysis of samples showed doses ranging from 16 to 165 mg. Acute reactions were rare and were usually confined to sensitive people taking high doses, particularly when they repeated the dose within a short period. Overdoses had unpredictable results: some effects lasted up to 2 weeks. Psychosis, including paranoia and hallucinations, usually resulted from very high dosages.

The paper includes two case reports:

1. A heroin addict who was adequately sedated had hallucinations and paranoia and was violent after a large dose of MDMA.

2. A normal 33 year-old woman who worked for a publisher took a large dose - estimated at 50 to 100 mg - with 4 friends. The trip was normal, with the woman still remembering it as the best time of her life. But one month later she took a normal dose from the same batch and within 20 minutes experienced feelings of dread and had visual hallucinations of the sky turning black and a devastated landscape spiralling in on her "like a ton of bricks". She lost consciousness and was taken to hospital where she had to be restrained for several hours. After 3 days she was regarded as normal, but stayed off work for a month. She was depressed, had bouts of crying and was not her normal self for 6 months. Laboratory analysis showed the batch of MDMA to be 95% pure and no other substances showed up in her body fluids.

The authors conclude that this unexplained case is disturbing, as the woman nearly died in conditions that are normally regarded as safe.

60 British Medical Journal vol. 305 August 1992 letters in reply to Henry's article

These letters variously reported: a case of acute hepatitis associated with repeated use of E, a case of jaundice associated with use of MDMA; and 3 cases of people suffering from severe chest pain after taking Ecstasy with alcohol.

61 Use of MDMA to relieve symptoms in terminal cancer patients; phase one protocol, by Dr. Charles Grob. (Fax received 17/11/92)

This is a safety and tolerance study designed to determine the psychological and analgesic threshold level for MDMA. Six subjects in the health care industry will be chosen for these trials. They will take part in 3 experimental sessions separated by two to four weeks.

Each session will consist of oral administration of one capsule, which may be either 0.15 mg/kg MDMA, 0.75 mg/kg MDMA or a placebo. Grob predicts that 0.75 mg/kg will be the threshold dose.

Tests will be carried out on subjects' blood, psychological state, experience of physical pain and on neuropsychological effects.

62 Designer Drug Confusion: a focus on MDMA, by Jerome Beck and Patricia Morgan, from Journal of Drug Education, 16/3/86

Beck and Morgan give a Cook's tour of the effects and clinical value of MDMA. They quote Wolfson: "MDMA provides a positive alternative to the dark and negative experiences of people experiencing psychotic states," Grinspoon: "MDMA appears to have some of the advantages of LSD-type drugs without most of the corresponding disadvantages," Siegel: "MDMA has been promoted as a cure for everything from personal depression to alienation to cocaine addiction. . . It's got a lot of notoriety, but the clinical claims made for its efficacy are totally unsupported at this time," and Greer: "Because every therapist I know who has given MDMA to a patient has found it to be of significant value, I am convinced that it can be shown scientifically to be efficacious."

They say that continuous use of booster doses after the initial dose to prolong the high produces great fatigue the following day. Regarding deaths ascribed to MDMA, "later investigation revealed that the role played by the drug, if it was even involved, was questionable in most cases." But Beck and Morgan say that the potentially toxic interaction between MDMA and alcohol merits further investigation. "As with other stimulants, individuals under the influence of MDMA are often capable of ingesting large amounts of alcohol."

A delayed anxiety disorder has been observed in a few individuals. This problem typically occurs among novice users of MDMA, and the manifestations range from a mild anxiety to a full-blown disorder such as a panic attack with hyperventilation and tachycardia, phobic disorders, parathesias, or other anxiety states. Usually the drug was taken in a nonprofessional setting for quasi-therapeutic reasons.

On the basis of interviews with such clients, it can be inferred that through taking MDMA, much of their repressed anxiety, hostility, guilt, or other so-called negative feelings were released into their conscious minds. . . After the release of this material, they are undefended and conscious of what emotional and psychological work needs to be done. These initial findings underscore a growing number of unsuccessful attempts at 'self therapy' by individuals who run the risk of exacerbating their emotional problems with unsupervised episodes.

They conclude that MDMA's unique effect is desired by many people and interest will continue to grow. MDMA could have a much greater long-term impact on our society than all of the so-called designer drugs combined.

63 Risk assessment and the FDA, by Rick Doblin, 1988.

A lecture on the history and current status of neurotoxicological research into the effects of MDMA. Doblin is president of the Multidisciplinary Association for Psychedelic Studies.

Doblin asked whether changes observed in animals given MDMA were permanent, produced behaviour changes and occurred at doses equivalent to those taken by humans.

Experiments on monkeys showed that nerve endings were damaged two weeks afterwards but were partially repaired in 10 weeks. Serotonin levels were partially recovered over a period of months, while one study on rats showed total recovery after one year.

He noted that researchers failed to identify distinguishing characteristics between untreated primates and those whose serotonin had been reduced by 90% and that no cases of MDA toxicity in humans had been noticed even though MDA is twice as toxic as MDMA and was popular in the sixties. Neurotoxic effects on primates given MDMA are only observable at about twice the human dose.

Tests of the mental health of MDMA users showed that their IQ levels were well above average, even though they had consumed an average of 13,000 mg - 100 times more than the therapeutic dose of 125 mg.

64 Markers of Neuronal Injury and Degeneration, by Miller and O'Callaghan.

Damage to the brain occurred with both mice injected with MDMA and those injected with fenfluramine, although not in the hippocampus or cortex, this study found. The result is significant in relation to O'Callaghan's work on rats as it shows that mice and rats are affected differently, implying that species is relevant to MDMA poisoning.

65 Fenfluramine Hydrochloride, from Martindale Pharmacopeia

The potential for abuse is considered to be virtually nonexistent. However, single oral doses of 80-500 mg were "used to elicit a psychotomimetic state consisting of euphoria, relaxation and inane laughter, often accompanied by perceptual alterations including visual hallucinations. . ." More frequent and vivid dreams were reported in 13 of the 20 people studied.

A study of 53 cases of fenfluramine poisoning through overdose showed that the most common symptoms were mydriasis, tachycardia and facial flushing. Nine patients died "following cardiac and respiratory arrest. Death occurred 1 to 4 hours after ingestion." (1979 German reference).

Fenfluramine should not be given to patients with glaucoma or a history of drug abuse or alcoholism. Patients with mental depression should be treated carefully; "there may be mood changes during fenfluramine treatment, and abrupt cessation can cause severe depression." Avoid use with epileptic patients. Excretion is via the urine "in the form of the unchanged drug and metabolites".

The drug is used as a short-term treatment for moderate to severe obesity.

The dose is initially 20 mg 2-3 times daily, increasing after the first week to a usual maximum of 120 mg daily. The drug is sold in the UK as Ponderax.

66 The Neurotoxicity of MDMA and Related Compounds, by Dr. Molliver, in The Neuropharmacology of Serotonin, published in Annals of the New York Academy of Sciences, 1990

A paper on studies comparing the action of MDMA with fenfluramine. It was found that the action of both drugs on serotonin (5HT) levels was virtually the same. After administration, the levels dropped and recovered with both drugs on similar time scales.

67 Fluoxetine, from Martindale Pharmacopeia

Fluoxetine is an antidepressant which selectively inhibits the re-uptake of serotonin. It has been shown to be superior to placebo in relieving depression. The dose is 20-80 mg daily. Its proprietary name is Prozac. There are several other SSRIs (Selective Serotonin Re-uptake Inhibitor) available.

68 A Trip into the Unknown, by Alison Abbott and David Concar, in New Scientist, 29/8/92

The authors estimate half a million E's will be taken "this weekend alone". "It is hard to build up a convincing case against the drug when you can't say exactly how dangerous it is or what the consequences of long-term effects are," they say. They make the following points: Britain has no long term research programme; the consensus is that ecstasy's hallucinogenic properties render it wholly unsuitable as a medical drug; figures released in August 1992 from the National Poisons Unit at Guy's Hospital showed that the drug had killed 7 people since 1990; pathologists are sure of the cause: heatstroke; Dr. John Henry of the NPU told them that everyone who takes Ecstasy is a potential victim, but is most worried by contamination of MDMA with heroin and ketamine.

MDMA works by blocking the return of 5HT [serotonin] to neurons by occupying its binding sites on the transporter protein. Once inside the neuron MDMA cannot be stored so leaks out again. As a result, the levels of 5HT in the synapses rise sharply in the short term, and 5HT signalling between neurons is amplified. The 'high' eventually fades when neurons become drained of their stored 5HT. Antidepressants like fluoxetine are thought to work by boosting levels of 5HT in the same way as Ecstasy. Most of the amphetamine-like effects are probably caused by increased levels of noradrenaline. The observed rise in body temperature in rats in hot environments may be caused by increased levels of 5HT in the part of the brain that regulates temperature known as the hypothalamus. This may render the hypothalamus unable to respond appropriately to overheating caused by dancing.

Research on rats shows the drug causes the nerve fibres or axons, through which 5HT neurons communicate with the rest of the brain, to break and swell. "On top of that, Ecstasy appears to block the activity of an enzyme called tryptophan hydroxylase, which neurons need to synthesise 5HT," the authors say.

"It could be years before the health risks of chronic abuse of ecstasy show up in the statistics," they conclude.

69 The MDMA Neurotoxicity Controversy: Implications for Clinical Research, by Dr. Charles Grob

Grob says that investigations to establish neurotoxicity often contain flaws in methodology as well as in interpretation. Damage presumed to be caused by MDMA is surprisingly limited and is confounded by associated variables. Authorised use of MDMA in Switzerland is "without reports of adverse neuropsychiatric sequelae".

Cases of compulsive self-administration are very rare. MDMA is unique among recreational drugs in that there appears to be a disinclination to take it repeatedly. "We believe that a thorough yet dispassionate review of the existing data suggests that experimental use of MDMA in humans can be justified, " Grob says. But this should only take place in controlled therapeutic conditions.

70 Ecstasy Revisited, by Bruce Eisner, Gnosis Magazine, winter 1993

As soon as MDMA was made illegal, it began to be adulterated, Eisner says. This was due to criminals replacing users and idealists in the manufacture and distribution of the drug.

Eisner makes the following point: "The same experiment that Shuster and Ricaurte did with MDMA and MDA - giving huge and frequent doses to rats - was also performed with a prescription drug, fenfluramine, used in treating eating disorders. No adverse effects have ever been observed from its use, and people who took it frequently many years ago have no observed brain damage or other problems. Fenfluramine is still prescribed, even though MDMA was quickly banned."

"With millions of people having taken MDMA over a 20-year period, some more than several hundred times, there has never been a reported case of MDMA-caused brain damage. Not one single case," he adds.

He quotes Shulgin as predicting that new compounds will inevitably be invented: "teased out of other drugs such as MDMA," which would have still greater specificity in triggering human emotions such as the fear of death, awareness and suppression of anger, and feelings of guilt.

71 Assessing Neurotoxicity of Drugs of Abuse, by Dr. James O'Callaghan, NIDA monograph 1993

Dr. O'Callaghan was contracted to do some research to establish a method of assessing neurotoxicity - this was a $750,000 project over 3 years. He says that the term neurotoxicity has no precise meaning, but he is taking it to imply that physical damage has been done to the brain which affects its function.

He found that, with rats, "even when we increased the methamphetamine dosage to as much as 150 mg/kg, twice daily for two days, we failed to see marked increases in Glial Fibrillary Acidic Protein (GFAP) at time points ranging from 2 to 9 days post dosing". Though "as little as a single administration of 20 mg/kg to the rat results in long-lasting decreases in 5HT levels" he found that 30 mg/kg MDMA twice daily for 7 days did not cause an increase in GFAP in the cortex, striatum and hippocampus although there was a decrease in 5HT. ". . . MDMA dosage regimen sufficient to produce a large and long-lasting decrease in 5HT was not sufficient to induce an astrocyte reaction characteristic of neural injury". When he increased the dose to 75-150 mg twice daily for two days, MDMA "produced a dose-dependent increase in the levels of GFAP in cortex and striatum at 2 days post dosing".

"Evidence for MDMA-induced neural damage . . . was not necessarily linked to . . . decreases in levels of 5HT".

O'Callaghan established Reactive Gliosis, a more direct and reliable method of testing for neurotoxicity. He also found that a method called silver staining produced reliable results.

[The relevant conclusion is that previous work on MDMA gave false results by assuming that damage was caused by a decrease in 5HT or serotonin. Extremely large doses, equivalent to someone taking 50 Es twice daily, did cause damage.]

72 fax from Rick Doblin, president of MAPS, 21/9/92

Doblin doubts that there is any neurotoxicity due to MDMA at normal doses. When primates were given oral doses of 2.5 mg/kg once every 2 weeks for 4 months (total of 8 doses) there was no evidence of neurotoxicity. But a single dose of 5 mg/kg did cause some slight reduction in the serotonin levels in two parts of the brain, the thalamus and the hypothalamus. So, it is possible that MDMA may be causing some toxicity in people who use especially high doses. Still, whether that toxicity is bad is not at all certain. In primates with 90% reductions in serotonin caused by massive amounts of MDMA (5 mg/kg injected every 12 hours for 4 days) there are no observable long term negative consequences. Still, damage may be too subtle to observe in primates.

73 Neurotoxicity of MDMA and related compounds: anatomic studies, Molliver et al. Annals of the New York Academy of Sciences, 1990

Axon degeneration is seen in fine 5HT axons (but not beaded axons or raphe cell bodies) within 48 hours after MDMA administration. Within six to eight hours, there is persistent serotonergic reinnervation of the frontal cortex along a fronto-occipital gradient in a simulating perinatal development of 5-HT innervation. Although the sprouting axons are anatomically similar to the damaged axons, it remains unknown whether a normal pattern of innervation is re-established.

74 Ecstasy: towards an understanding of the biochemical basis of the actions of MDMA, by Marcus Rattray, from Essays in Biochemistry, vol. 26 1991

Rattray reviews some of the complex biochemical actions of MDMA and discusses how these may relate to the psychopharmacological and neurotoxic effects of the drug.

After a single dose, 5HT depletion is rapid and remains low for 6-18 hours, recovering within 24 hours. This coincides with observed effects of MDMA. It is therefore likely that psychotropic effects can be ascribed to the post- and pre-synaptic effects of released 5HT.

Studies using brain slices pre-loaded with 5HT have shown that micro-molar concentrations of MDMA induce 5HT release. It has been proposed that the MDMA taken up by nerve terminals causes the displacement of 5HT from cytoplasmic binding sites, leading to 5HT efflux through the synaptoic membrane 5HT transporter. . . . this is taken as evidence that the neurotransmitter released is derived from cytoplasmic stores rather than from the 5HT stored in synaptic vesicles.

Drugs such as fluoxetine known to block 5HT uptake into nerve terminals are found to inhibit the release of 5HT induced by MDMA. Current evidence suggests that the primary action of MDMA is on the nerve terminals of neurons that synthesize and release the amine neurotransmitter serotonin or 5HT.

Answering the question: is MDMA toxic to man? Rattray says:

In all the studies that have found neuro-degeneration in animals, several large doses were administered over a very short time period, so it is difficult to extrapolate to humans. The route of drug administration (oral in humans) is a significant factor [ref. to Ricaurte 1989]. Nevertheless, it is likely that levels of consumption in man can produce brain concentrations that approach toxic doses. At the present time there are no reports of MDMA-induced neuro-degeneration in humans.

75 Letter from Jeremy Millar, Department of social work, Aberdeen University, 20/11/92

Millar reports on a young man, diagnosed as schizophrenic, who has been using Ecstasy for 3 years along with amphetamines and LSD. He prefers Ecstasy, and while on Ecstasy his behaviour and thought processes improve as witnessed by himself, his parents and his social worker. He can also communicate clearly.

76 MDMA - Non-medical Use and Intoxication, by Ronald Siegel, from Journal of Psychoactive Drugs, Vol. 18/4 1986

This is a survey of a representative sample of drug users who had used MDMA at least twice in the previous year alongside other drugs. 44 such drug users answered a questionnaire. Siegel found that 90% of hard drug users who had tried MDMA did not want to repeat the experience - most found little or no effect and the rest did not enjoy it - and that samples contained about 20% less MDMA than was claimed by dealers, but none contained active impurities.

77 Lifeline, Ecstasy, and the world, by Mark Gilman

Mark Gilman, a researcher with Lifeline, a non-statutory drug agency in Manchester, gives the agency's official view of Ecstasy: that it is neither all good nor all bad.

The dangers were:

1. Not getting a real MDMA tablet.

2. Taking too much too often. This may cause damage, but it is also dangerous to take depressant drugs to 'turn off' the unwelcome anxiety states that accompany taking 'too much [Ecstasy] too often'.

3. Risk of heatstroke.

Young people using E have their eyes opened to the world of illegal drugs and lose respect for the law. Makes young people into criminals. In this sense, E is to the nineties what LSD was to the sixties; the difference is that now many other drugs are available too.

Gilman concludes: "I suspect the environmentalist/green movement will benefit from the boom in E just as the sixties counter culture grew alongside LSD use. I also suspect that we will begin to see the popularity drugs grow and grow - a new psychedelic dawn? What is clear is that a lot of people's world views have been changed by their Ecstasy experiences. Comparisons with the sixties are in order here."

78 No more junkie heroes? by Mark Gilman, from Druglink May 1992

Gilman says that the up and coming users of illicit drugs regard them as an adjunct to fun rather than the organising force of their lifestyle. There are many more of them than in previous generations and they use amphetamines, cannabis, LSD, Ecstasy and, sometimes, cocaine. They do not inject and are not dependent on their chosen drug. The most pressing policy task is to keep this group as far apart from opiate users as possible. This should be relatively easy as many of the younger drug users hold strong anti-injecting and anti-opiate views and refer to junkies in highly derogatory terms such as 'old and smelly'.

79 Ecstasy and Recreational Drug Use in Wirral by C Toddhunter, Liverpool University

Between March and June 1992, 95 drug users participated in this survey. Of the 57 who had used Ecstasy, 52 were interviewed. The following conclusions were drawn:

First time E users tend not to be new to drug taking. Only 1 out of 52 respondents used E before they had tried any other drug and only 3% of respondents had used E prior to the age of 16/17.

Nearly 95% had a history of drug use which included LSD, cannabis and amphetamine prior to taking Ecstasy. Most of them commonly used more than one drug. 96% used E in conjunction with other drugs at raves. Use of Ecstasy took place almost exclusively at raves or where House Music was played.

A strong anti-heroin culture was found among Ecstasy users. There was a tendency for most of those interviewed to regulate and limit their drug use to avoid problems. A small minority who made little attempt to control their use faced serious problems as a result, including paranoia, weight loss and diminished mental activity. Most of these people took Ecstasy, LSD and amphetamine.

Ecstasy had fallen in price: it cost #9-#15 at the time of the survey. Whereas some respondents had a history of Ecstasy use but had drifted away from the drug, the total number of users had not fallen.

Among Ecstasy users, there is a strong rejection of conventional night life culture including even moderate alcohol consumption. Alcohol is perceived to be a bigger AIDS risk, as rave culture is less concerned with sexual gratification. Instead, gratification comes from the intensity of the music and dancing.

Ecstasy users are very keen to obtain factual knowledge about drug use in their own terms, as opposed to what they perceive as misinformation by the media.

"A minority of young people in Wirral shows a firm attachment to Ecstasy use. It is as acceptable and conventional to them as drinking alcohol is for the wider population," Toddhunter says.

80 Hansard 17/1/1992. Written answers by John Patten, then Minister of State at the Home Office

The number of deaths attributed to MDMA or MDA was one in 1988; three in 1989; one in 1990; and two in 1981 A note says that 1991 figures are up to September only and "deaths of this nature result in an inquest and thus delays of registration of up to one year may occur". Thus 1991 figures were incomplete.

81 Phone call to Mr R Allen, at the Home Office Statistics Dept., 1/3/93

The Home Office does not have recent statistics on drug-related deaths; the latest it holds are those reported in Hansard80. Allen says that the Home Office's only knowledge of deaths that have occurred in the past two years is from newspaper reports. [These are of course unreliable]. He said: "The truth is between 10 and 20 deaths so far are 90% suspected to be due to Ecstasy - but don't quote this as a Home Office figure. These are people who have either died from overheating or from a rare extreme reaction, just as some people have been known to have died from a bee sting."

However, an attempt is now under way to produce figures more on the lines of DAWN, the US system of monitoring drug-related deaths.22 "We have people going through wads of death certificates," Allen said. However, figures are unlikely to be ready before the end of 1993.

82 Deaths reported by the mass media related to raving and/or dance drugs, 1989 to 1993, from Rave Research Bureau, 25 Halkyn Avenue, Liverpool L17 2AH

This is a 3-page list of media-reported deaths related to use of dance drugs, giving victims' sex, age, area of residence, the drugs they had taken, the number of such drugs, the place of use and the date of death. The source of information is given for each victim.

30 deaths are listed, of which 16 are attributed solely to MDMA and one to MDEA, while MDMA is mentioned as a possible contributory factor in a further 5. Of the deaths attributed solely to MDMA, two were said to be due to liver and/or kidney failure while another was due to heart failure. No other possible contributory causes of death were given. With the exception of two cases, no details aregiven of whether MDMA was found in post mortems.

83 Licensed to Thrill, in New Scientist, 29/8/92

An article on safety at fairgrounds. There are 10,000 rides in Britain catering for 500 million passengers a year. The chance of death or serious injury was 6 in 100 million. Someone taking 100 rides a year would run a risk of death by accident on a ride of 4 in 10 million, which is more than being hit by lightning but less than dying of cold. They would be seven times more likely to die driving to the fairground than while actually there.

84 Skiing dangers, The Sunday Times, 24/1/93

Among nearly five million skiers in Switzerland last year, 11 people were killed and 3% were injured.

85 Rave- and Ecstasy-related admissions in West Lothian 1991-1992; a review by Dr. P. Freeland submitted for publication to The Annals of Emergency Admission

Dr. Freeland's review examines the frequency and nature of presentations to West Lothian hospitals in 1991 and 1992 following the ingestion of drugs in the context of rave parties, by means of retrospective analysis of case notes.

He found a total of seven cases; six having said they took Ecstasy and at least two having taken other drugs in combination with Ecstasy. Six were aged between 18 and 21 and the seventh was 27. Five were male. The invariable clinical finding was tachycardia - a racing heart. Complaints on admission included "buzzing sensations", anxiety and collapse. One patient admitted taking Ecstasy, Temazepam, cannabis and a cocaine-related drug in combination on the evening of admission to hospital. He had a high temperature (39.5 degrees C) and developed acute renal failure and coagulopathy - kidney failure and blood clotting. He recovered and was discharged after 18 days.

Another had taken Ecstasy, amphetamine and cannabis and complained of palpitations and a "buzzing sensation". He was discharged the next day. In addition, one patient had severe muscle spasms: this patient did not admit to taking any drug, but amphetamine was found in his blood (MDMA was not looked for).

The other patients, including all those who admitted to taking Ecstasy, discharged themselves. There were no fatalities.

The minimum hospitalisation rate is calculated to be 23 per 100,000 rave attendances, based on venue capacities.

"Although the study aimed to look particularly at MDMA, the high prevalence of multiple drug use and the absence of specific toxicological results on these cases make it impossible to pass any judgement on MDMA per se," Dr. Freeland concludes.

86 The Psychological and Physiological Effects of MDMA on Normal Volunteers, by Joseph Downing, from Journal of Psychoactive Drugs, Vol. 18/4 1986

This study examined the effects of MDMA on 21 healthy volunteers, including 13 men and 8 women, between the ages of 20 and 58. Their average age was 39. The volunteers had all previously used MDMA, an average of 8 times. All thought they had benefited from it and had recommended its use to others. Doses were chosen by subjects and ranged from 0.8 to 1.9 mg/kg of subjects' body weight, averaging 165 mg. There were no added doses.

Downing notes that oral doses administered in therapy are less than 1 per cent of the LD50 (the dose that kills 50 per cent of rats or mice given the drug), implying a high margin of safety.

80% of the subjects experienced jaw clenching, 60% headaches, and 60% eyelid twitches. None objected to these effects.

Blood pressure and pulse rate increased in all subjects. The peak was between half and one hour after taking the drug. Peak blood pressure was over 100 mg mercury, with one subject's blood pressure reaching "200/100" and their pulse increasing from 72 to 148 within 30 minutes, and subsiding to 128. Most subjects' blood pressure had dropped to below the level it was at before they took the MDMA after 6 hours. Some subjects' blood pressure was still below this level after 24 hours. This did not depend on dosage. Blood analysis yielded no significant results.

Subjects were examined before ingestion; in the second and the fourth hours after taking the drug and 24 hours after.Subjects' state of consciousness, measured by alertness and lucidity, was not impaired at any time. There was no evidence of confused thinking at any point. All reported their attention focused on the here and now.

Subjects' short-term memory was unchanged, but half the subjects had difficulty multiplying numbers, apparently because of difficulty in focusing on the task. Nearly half the subjects' judgement was impaired, implying that decision-making should be postponed or decisions should be re-evaluated after taking MDMA.

All subjects had dilated pupils and reflex to light was maintained. Nastygmus was present in nearly half the subjects, usually ceasing within 2 hours but lasting 24 hours in 2 cases. Half the subjects had jaw clench, which ended within 4 hours except with one subject who had it mildly after 24 hours.

Finger-to-nose testing was impaired in 2 subjects. Gait and coordination were affected in a third subject, suggesting driving could be dangerous. All the subjects' appetites were depressed over 24 hours.

Downing concludes that under the conditions tested, "MDMA has remarkably consistent and predictable psychological effects that are transient and free of clinically-apparent major toxicity".
87 Phone conversation with Mike Evans, at the Home Office 25/2/93

The Home Office can and does issue licences for research using MDMA, including trials on humans. Licenses are not issued for medical use, and in fact this is proscribed due to the drug being classified under Schedule 1, the category for drugs which are considered to have no medical use.

88 Statistics of Drug Seizures, up to the end of 1991 from Home Office Statistical Bulletin, published by the Government Statistical Service, September 1992

There were 1,700 seizures of MDMA in 1991, compared to 400 in 1990 and 770 in 1989. Only two police forces (both in Scotland) did not report seizures and in 30 per cent of police forces MDMA was the most frequently seized class A drug. The Metropolitan Police in London and the Merseyside, Lancashire, West Yorkshire and Strathclyde police forces each reported more than 50 seizures. The number of doses seized was just over 365,000 compared with about 44,000 in 1990. 1991 saw a substantial increase in the use of cautioning as a penalty for drug offences of all kinds. As in 1990, more drug offenders were cautioned than fined, which was previously the most common penalty. Between 1981 and 1991, the proportion of drug offenders receiving cautions increased from 1% to 45% and the proportion receiving fines fell from 65% to 30%. The proportion given prison sentences (with immediate effect) fell from an average of 15% between 1984 and 1987 to 7% in 1991. The likelihood of a stiffer penalty rose with the age of the offender: in 1991 80 per cent of males aged under 17 were cautioned, but only 25 per cent of males aged 30 or over. About half of unlawful possession offences resulted in a caution, with one third of such offences resulting in a fine, while between 30 and 40 per cent of most types of trafficking offences resulted in a prison sentence.

89 Interview with Detective Chief Superintendent Derek Todd, Drugs Coordinator with the No 9 Regional Crime Squad, at Spring Gardens, London, 16/2/93

On April 1 1993, Todd was promoted to assistant coordinator of the new South East Regional Crime Squad, an amalgamation of the No 9 Squad with the No 5 and No 6 Squads, with special responsibility for drugs.

Todd says he believes the way to control drug use is by reducing demand, rather than supply. If there is a demand, it will be supplied somehow. The answer is to try to prevent use. Instead of taking people to court who are caught with drugs for their own use, he would prefer to be able to force such offenders to attend counselling sessions aimed at educating them about the dangers of drug use. Compulsory attendance of such sessions would continue until tests showed that offenders were drug free. When I suggested that if counselling reflected the truth it would inform users that MDMA is no more harmful than alcohol, Todd agreed that alcohol was bad but said that two wrongs don't make a right. He accepts that young people will take drugs whatever is done by the authorities, but says that if no action is taken we will end up with a society where drug taking is normal. "I will fight to prevent that," he said passionately.

Todd believes that the reason that Ecstasy is so popular and has reached parts of the population that no other drugs have reached, is that it has been marketed better than other drugs.

Asked about his attitude to harm reduction policies, Todd replied that he is in favour of harm reduction in principle, provided it is first emphasised that taking the drug is against the law. He showed me a leaflet that emphasised the need to look after oneself when taking drugs, rather than the illegality of the drugs. Advice on what to do in relation to one drug may be harmful if applied to another drug, and this could occur because people were often sold a different drug to the one they thought they were buying. Harm reduction policies should directly promote healthy practices, and not encourage people to think they can safely use drugs which may cause casualties.

Todd said that he believes ideas about liberalisation are never thought through. Any changes in the law on drugs have to be international and simultaneous, or problems are created. For instance, Holland allows legal manufacture of MDEA and the growing of cannabis and these drugs are exported to England. The British police have been successful in finding MDMA factories in the UK, but this has only resulted in manufacturers moving abroad.

One clandestine factory was found in a garden shed in a garden centre open to the public. The operators had no qualifications but had been taught by chemists; they had instructions for making MDMA pinned up on the wall. They produced batches of about 20 kgs. Each batch took 24-36 hours to make and was then left to dry. Todd says that the ideal time to raid is when one batch is drying and another is being made, otherwise it may be that either no manufacture can be proven, or that there is none of the illicit product on the premises. The main way of catching manufacturers is through informers; but sometimes suppliers of equipment and chemicals will notify the police who then follow their deliveries.

Asked about penalties for Ecstasy use, Todd said that he "didn't advocate prison for popping an E". However, MDMA is a Class A drug and is in that category because it is regarded as dangerous. This view is upheld by respected experts such as Dr. John Henry. People have died as a result of taking the drug, and so others must be protected. In fact people caught with Ecstasy are often cautioned, but this is largely because the testing labs are 'snowed under' (or under-funded). In December 1992, the Metropolitan Police lab had a long waiting time for drug tests: if the charge was supplying drugs, the wait was 47 days; if only 'in possession', 50% of samples were tested within 71 days and the rest took up to 92 days. This made it preferable for the police to get an admission from a suspect that the substance found was an illegal drug and then to give a caution. Todd says that suppliers are generally not Mafia or Kray Brother types. Over the past four years there has been a trend towards the "standard British criminal", who 20 to 30 years ago would have done an armed robbery, turning to drug dealing or any other scam.

90 Phone conversation with Arno Adelaars, an Amsterdam-based part-time purchaser of street samples of drugs for testing by the Dutch Government, 25/2/93

Adelaars says the Netherlands Institute for Alcohol and Drugs in Utrecht produced a report in February 1993 recommending that MDMA be reclassified as a soft drug, but that this recommendation is likely to be ignored by the Dutch parliament.

91 Interview with Detective Chief Superintendent Tony White, head of the drugs and money laundering branch of the National Criminal Intelligence Service, which is under the control of the Home Office. At Spring Gardens, London 19/2/93

The drugs and money laundering branch of the NCIS collects and disseminates information for both the police and customs. White spends a large part of his time abroad coordinating activities with the police and customs officers of other Governments.

Over the past year there has been a 60% increase in the number of seizures without any increase in the number of doses seized (144,000), implying that the police were picking up dealers nearer the consumer end of the distribution network.

White gave me a copy of a chart from the winter 1992/3 edition of Drugs Arena, a glossy magazine published by the NCIS that is distributed exclusively to drug law enforcement officers. The chart showed seizures of MDMA, MDA and MDEA since 1990. He says that periods in which there were few seizures of MDMA saw increased seizures of LSD, indicating that LSD and MDMA were alternative drugs used by the same group of people.

I asked whether police policy varied according to the dangers of the particular drug, and what the policy towards Ecstasy was. White, who emphasised that he could not speak for the police, replied that policy for action against drugs was largely "political" in the sense that enforcement efforts against drugs had to be weighed against other interests such as education, health and community relations. Many drugs were associated with particular ethnic groups and the police had to weigh up the damage that might be caused to their relationships with these groups against the desirability of preventing use of such drugs. However, there are no such problems with Ecstasy, so police action is unfettered. The police response to particular drugs does not depend so much on the precise dangers of the drug in question as on the perceived public concern about the drug. Commander John O'Connor of the Metropolitan Police says in a recent report that the policy of arresting dealers has largely failed, and suggests going for the users instead. White gave some support to this idea by saying that dealers would find no market if there was no demand.

Asked for his predictions of future trends in Ecstasy supply and use, White said that British developments would depend on what happened in Holland. I asked what the effect on British Ecstasy users would be if the Dutch tightened up enforcement of their laws relating to MDMA. He replied that, in the short term, there would be a further rise in amphetamines being sold as Ecstasy and in the use of LSD and in the longer term, more manufacturing of MDMA in Britain. I asked whether that would be a good thing, and he replied that there was no easy solution: "It's like a war," he said. However, there was now effective international control of precursor chemicals. He also told me that anyone convicted of supply has all their assets confiscated unless they can prove other sources of income.

White says he believes it is a myth that Ecstasy users are a separate group from those who use addictive drugs. He says that once a market for any drug is established, users will switch to any other drug including addictive and dangerous ones. He also believes that dealers mix addictive drugs in with MDMA in order to get clients hooked. The best advice, he says, is "just don't do it".

Factories are set up in Britain and in Holland, typically by middle-aged English criminals who have been to prison several times for such offences as armed robbery. Dutchmen are also involved.

White says police action is misunderstood when it comes to stopping raves, as the use of drugs is a very minor motive. The reasons are, in order of priority, (1) Public safety. (2) Public order. (3) Public Nuisance. (4) Use of drugs. He believes that very little drug dealing goes on at raves, because Ecstasy "takes about 4 hours to have its full effect" and so users take it before they arrive at the rave. [In fact MDMA, MDA and MDEA reach their full effect within about an hour.]

92 Media Seminar held on 17th November in London 1992 as part of European Drug Prevention Week

The seminar was presented to "a thousand opinion formers to promote a coordinated long-term drug prevention campaign for Europe". [I asked to attend but was refused.]

The host was Emma Freud who stated that the object was to use the media to form attitudes in young people. She said the media has portrayed Ecstasy in a way that has created a wave of interest, and that there may be an argument for suppressing information. Nick Ross replied that the media does censure a great deal, but in the case of Ecstasy "It was all the rave, and the rage, before we knew about it". He added that politicians must not look to the media to manipulate society. Janet Street-Porter was then asked if she agreed, and replied: "Yes, I certainly don't think it's the role of the BBC to put across PR messages on behalf of the government. I think it is the job of Nick and myself to illuminate people"

The final words were an appeal from a bishop: "If the government says that Ecstasy is always dangerous, if the church says that it is sinful and doctors say that in many cases it is fatal, then we might change the situation."

93 'Ecstasy and intracerebral haemorrhage, by JP Harries and R De Silva, in The Scottish Medical Journal, October 1992

This paper reports on four cases of intracerebral haemorrhage related to the use of amphetamine or Ecstasy that presented to the Institute of Neurological Sciences at the Southern General Hospital in Glasgow over a ten week period in 1992. None of the patients were given blood or urine tests to confirm the presence of a drug or identify the type of drug taken. One patient, a 20 year-old man, died after a stroke, having had his soft drink spiked with Ecstasy in a pub at lunchtime. Doctors discovered a large frontal haematoma - or blood clot - in his brain when they gave him a CT scan and a left frontal angioma. They operated, but the patient was declared brain dead the following day.

A previously healthy 30-year-old woman who was brought to the unit suffering from a sudden attack of headache, dysphasia - a speech disorder - and hemiparesis (paralysis) affecting the right half of her body, informed doctors that she had taken a mixture of Ecstasy and amphetamine at a party just prior to the onset of her symptoms.

An anonymous phone caller informed doctors that a 22-year-old woman, who was brought to the unit after having an epileptic fit following a sudden onset of severe headache, urinary incontinence and agitation, had taken amphetamine sulphate just prior to the onset of her symptoms.

A sixteen year-old boy was admitted to the unit, who had a mild right hemiparesis with an expressive dysphasia and blood pressure of 130/70. He had been drinking cider with his friends and his drink had also been spiked with Ecstasy, the paper says.

They conclude: "The close timing of our four cases makes us suspicious that impurities in a batch of drugs may have been a major factor in the concentration of cases in Glasgow over such a short period."

94 Interview with Rick Doblin, president of the Multi-disciplinary Association for Psychedelic Studies in High Times, December 1992.

Doblin talks about the way MDMA was outlawed in the US.

When the Drug Enforcement Agency tried to get the World Health Organisation to place MDMA in the international drug treaties, a very fortuitous thing happened. The person appointed chairman of WHO's Expert Committee was Dr. Paul Grof, brother of Stanislav Grof, the LSD researcher. [Through him] I was able to send information about MDMA to Paul Grof. Though the committee did make MDMA illegal, they did so over the objections of the chairman, with the objections being formally noted in the committee's recommendation. Even more importantly, the committee explicitly encouraged the signatory nations to the international drug control treaty to facilitate research into MDMA, which they called a most interesting substance.

95 The Swiss Medical Society for Psycholytic Therapy. President: Dr. Med. Juraj Styk, Birmannsgasse 39, 4055 Basel, Switzerland

The society's address is that of the president's consulting room. There are some 30 members but only four are licensed to practise with MDMA and LSD.

96 Listening to the Heart of Things (book), by Dr. Samuel Widmer, a Swiss psychotherapist who uses MDMA with some clients, subtitled The Awakening of Love, published by Nachtschatten 1989

This book is in German but may soon be available in English, too. It covers the work of Dr. Widmer up to 1989 using LSD and MDMA in psychotherapy. The book has three sections: (1) The unwanted psychotherapy. (2) Beyond duality - the awakening of love. (3) Psycholytic psychotherapy.

[Some case histories from this book are summarised in chapter 9.]

97 Dancing and rave drugs, by Russell Newcombe, 1991

Newcombe suggests that clubs are safer than raves because of fire and other health precautions, and argues that police and local authorities should not therefore try to close clubs where drugs are used. Drugs are often taken before entering. "It would be no exaggeration to say that raving is now one of the main reasons for living for a huge group of socially diverse people aged between 15 and 35 years," he says.

98 Can drugs enhance Psychotherapy? by Grinspoon and Bakalar, from American Journal of Psychotherapy, 1986

The authors say that compared to LSD, MDMA is "a relatively mild, short-acting drug that is said to give a heightened capacity for introspection and intimacy along with temporary freedom from anxiety and depression, and without distracting changes in perception, body image, and the sense of self". These effects should be of interest to Freudian, Rogerian and existential humanist therapists, they argue.

MDMA strengthened the therapeutic alliance by inviting self-disclosure and enhancing trust. Psychiatrists suggested it was also helpful for marital counselling and diagnostic interviews. Patients in MDMA-assisted therapy reported that they were released from defensive anxiety and felt more emotionally open, which made it possible for them to get in touch with feelings and thoughts which were not ordinarily available to them. It was easier to receive criticisms and compliments. A patient said that the major difference in psychotherapy that included taking MDMA was "being safe. Nothing could threaten me". A patient who found she was more in touch with her feelings and could express herself more easily 18 months after her last MDMA session is cited as evidence that MDMA has lasting benefits.

The authors say MDMA may also help in working through loss or trauma, supported by the following anecdote. A patient said that after a session where she had grieved the loss of her boyfriend, she was surprised at feeling pleased with herself for having grieved so deeply.

Many MDMA patients claimed lasting improvements in their capacity for communication, such as getting on better with marriage partners. Increased self-esteem was also lasting.

The authors conclude that many pre-industrial cultures use certain psychedelic plants to enhance a procedure that resembles psychotherapy. MDMA was a far more suitable psychotherapeutic aid to substitute for this than the true psychedelics tried in the sixties.

99 Ecstasy: the clinical, pharmacological and neurotoxicological effects of the drug MDMA (book), edited by Stephen Peroutka, published by Kluwer Academic Publishers 1990

This is the classic serious work on MDMA but costs about #100. The book includes essays by a range of experts in the field: The History of MDMA by Shulgin; Therapeutic Use by Greer; Testing Psychotherapeutic Use by Bakalar and Grinspoon; Recreational Use by Peroutka; Toxicity by Dowling.

There are 13 chapters in all.

MDMA is unique among recreational drugs in that taking larger or more frequent doses reduces the pleasant effects and increases the bad effects. It is also unique in that the effects change with successive doses, the first being the most pleasant while further uses produce more uncomfortable side effects. [This view is challenged in a more recent report.26]

Therapeutic use

"MDMA seems to decrease the fear response to a perceived threat to a patient's emotional integrity, leading to a corrective emotional experience that probably diminishes the pathological effects of previous traumatic experiences," Greer says. Double-blind comparisons are not feasible in clinical settings because the MDMA state is easily perceived by both the patient and the therapist. Suggested therapeutic uses include family relationships and drug addiction.

The effect of MDMA was seen as secondary by the therapists: the drug assisted rather than caused the desired outcome. The goal of developing a more compassionate attitude towards oneself and others was easily achieved in MDMA-assisted therapy. Of paramount importance was the quality of the relationship between the client and therapist: enabling the client to feel safe to open up fully was seen as more important than the dose of MDMA taken. It was considered essential that the therapists tell the client that the client's MDMA trip had been helpful to them, in order to reassure the client. For therapists, "The experience of fearless communication and spontaneous forgiveness, or letting go of resentments, was particularly important in understanding how MDMA can be used effectively."

The screening of prospective clients is very important. Those with heart problems; those using psychoactive medication; epileptics; hyperthyroids; diabetics; hypoglycemics; hypersensitive people and those with liver disease or other risks of morbidity should be excluded. Although the drug was considered useful for those with psychiatric problems, therapists worked only with relatively well-adjusted people. They excluded those who aroused uneasiness on interview. Patients were warned about the possible adverse side effects, and this resulted in several opting out.

The therapists preferred to work as 'sitters' or assistants to patients who were exploring themselves rather than to become involved in a long term therapeutic relationship. Patients could ask for anything they wanted during sessions. [Agreements given under Greer.28]

Discussing unwelcome effects of MDMA, therapists mentioned the pain of unfinished grief or trauma associated with forgotten memories or repressed feelings, which often resulted in depression and/or anxiety. This was usually experienced as difficult but useful, and seldom lasted more than a few days. They had not heard of long-term problems resulting from such feelings.

Since the outcome of MDMA sessions cannot be predicted, patients were warned to be prepared to experience anything that might arise during or after their session. They had to have a conscious desire to be open to the most painful experience of their past so as to be able to work through it. "You are consciously taking a medicine to open yourself to whatever teachings you may need at this time. Neither you nor we know what these teachings are or how they may occur. We will provide a safe place for your explorations and be available to assist you with any difficulties, but all that you learn that is real comes from yourself or from the Divine that is within you - not from us or the medicine itself," one therapist would say. Preparation was seen as important. It was felt to be useful for clients to have clear expectations, which made it easier for them to let go. Clients were advised not to take alcohol and other drugs for the preceding few days, as this is thought to reduce the effect of MDMA, and to eat no food for the preceding few hours.

Patients were asked whether they wanted a low, medium or high dose. For men, this was 100 to 150; for women 75 to 125 - women were thought to be more sensitive to the drug, perhaps due to their lower body weight. Higher doses were advised for those focusing on themselves; lower doses for couples wanting to communicate with each other. The therapists' main role was to provide for physical needs and to offer interpretations as required. Dr. Greer advises clients to relate their experience afterwards, rather than have their therapist record the trip in process. If a monologue occurred, he suggested the use of a tape recorder to focus attention inward, rather than towards the therapist. After the drug wore off, patients usually sat up and talked about what had happened. Therapists did not routinely offer to interpret clients' experiences, but tried to facilitate a smooth transition back to normal.

About 90% of the clients had powerful and generally positive and useful experiences under MDMA. A third of these had had one session; another third, two and the rest, three or more.

The book also includes a report of a survey of Ecstasy use among students at Stanford University. 39% of students had used MDMA. 100 completed a questionnaire while under the influence. The results were unsurprising: 90% reported increased closeness with others.

Also included is a report of Ecstasy-related deaths involving heart failure and asthma that have been investigated in the US.

100 The Biology of Human Information Processing by Enoch Callaway from Journal of Psychoactive Drugs Vol. 18/4 1986

The paper starts with the premise that humanity's most pressing problem is to understand the human mind; to date, progress has been disappointing; and psychoactive drugs hold most promise. The most important use of psychoactive drugs, and MDMA in particular, is to help understand the human mind. No laboratory way of assessing love exists.