Her friends were there in the club when she became pale and sweaty. Then her eyes glazed over and she started to collapse. They grabbed her before she fell to the floor and that's when her body started to shake and jerk uncontrollably. 911 was quickly called...

In the Emergency Department, the paramedics explained the she had had a seizure, which lasted about 5 minutes and that she had bitten her tongue and hurt her arm with the thrashing. The doctor asked her if she had ever had a seizure before and she answered, no. Was there any drug or alcohol use? He asked. She remembered the ecstasy she had taken earlier, but that couldn't have been the cause of her seizure. Her friends had taken it many times before and they had always been fine. Right?

It is believed that more than 8.3 million people world-wide have used ecstasy, and it is widely available at parties, clubs, concerts and raves across Canada. Surveys show that up to 39% of teens and young adults have used ecstasy at least once. But what exactly is ecstasy and what makes it so popular? How does it work and what effects does it have on the body?

The chemical name of ecstasy is quite a mouthful, methylenedioxymethamphetamine, or MDMA for short. Street names are constantly changing, but include "X-TC", "Adam", "clarity", "Stacy", "lover's speed", essence" and simply "M," "X" or "E".

MDMA is classified as a stimulant, a class of drugs that include caffeine, nicotine, cocaine and amphetamines. It is produced by chemical reactions involving an amphetamine and a hallucinogen. But, it is not as addictive as other amphetamines, like speed and ice, or as hallucinogenic as LSD or mushrooms, features that contribute to ecstasy's popularity. (Note: for more on addiction see January's issue of The Clinic: Understanding Addiction)

Did You Know?
Ecstasy is a combination of an amphetamine (i.e., stimulant) and a hallucinogen (i.e., a chemical that distorts perception and/or alters sensory perception) Believe it or not, MDMA was initially created as a diet pill for animal experiments, but when the rats didn't lose any weight, scientists gave up on it. About fifty years later, U.S. spy agencies re-discovered it and attempted to use it as a type of "truth serum" and then psychiatrists used it for psychotherapy. Once again, the drug was not very useful. In the 1980s, it was realized that the drug's effect on emotions and sensations, causing feelings of extreme well-being, enhanced social intimacy and loss of inhibitions, would make it a popular recreational drug...And they were right. Despite making ecstasy illegal in 1985, the use of the drug increased and peaked in the 1990s with the growing popularity of raves. It continues to be the drug of choice by many party-goers.

There are many other reasons why ecstasy has become so popular. Firstly, it's easily attainable and affordable. Secondly, it's available in a pill form, which is easy to take and perceived by users as a safer method of delivery compared to inhalation and injection. But, who makes the pills and what exactly is in it?

The production of ecstasy is increasingly done by amateur chemists in "basement" labs. Improper chemical reactions can lead to toxic products with the potential to significantly harm a person's health. In addition, producers may combine other drugs into the pills as "filler". Seized pills have been found to contain substances such as LSD, speed, and the "date rape" drugs GHB and ketamine. Unfortunately, it can be impossible to predict the effect of impure ecstasy on the body.

Did You Know?
Many "homemade" version of ecstasy contain impurities that add to the drug's toxicity In its pure form, ecstasy works at the level of the brain, specifically with respect to neuron communication. Most neurons rely on chemicals that they produce to act as messengers, called neurotransmitters. Examples include dopamine, epinephrine, norepinephrine and serotonin. When a message needs to be sent from the brain to the rest of the body, neurons release neurotransmitters into the space between neurons known as the synapse, allowing the neighbouring neuron to detect the message. Once the message has been received, a molecule known as monoamine oxidase (MAO) will break down the neurotransmitter, preventing unwanted repeat messages from being sent.

Ecstasy mainly affects serotonin by increasing its release from neurons and preventing its breakdown by MAO. This leads to larger than normal amounts of serotonin at synapses. Since the release of serotonin is known to improve mood, this explains why ecstasy causes a person to have an enhanced sense of well-being. However, serotonin also has other effects on the body, including regulating body temperature.

Did You Know?
Ecstasy results in increased serotonin levels in neuronal synapses, which leads to changes in mood and body temperature The most common side effect of ecstasy is more of a nuisance than a danger: it consists of the stiffening of jaw muscles and/or teeth grinding. This can be relieved by sucking on a lollipop or a pacifier. Another well known side effect, but much more concerning is hyperthermia, or an elevated body temperature. In severe cases, hyperthermia can lead to muscle damage, kidney and other organ failure. Hyperthermia accounts for most of the reported deaths caused by ecstasy. It is impossible to predict who is susceptible and it can occur with first-time ecstasy use. For milder cases of hyperthermia, which are far more common, many users know to drink water and other fluids to prevent dehydration.

Did You Know?
Changes in neuronal signaling that result from taking ecstasy can lead to muscle stiffening, hyperthermia and dehydration However, too much fluid can be dangerous. With the usually hot, crowded environment, increased physical activity, hyperthermia, and the possible alcohol use, it is not unusual for an ecstasy user to drink large quantities of water. The complication is that ecstasy causes the release of a hormone called antidiuretic hormone (ADH). This hormone acts at the kidney to cause water retention, leading to even more water in the body. Both the consumed and retained water dilute the body's natural salts to abnormally low concentrations. This can cause drowsiness, nausea, vomiting, muscle pains, headache, agitation, seizures, and, uncommonly, death.

Did You Know?
Hormonal changes that result from taking ecstasy cause water retention, which, when combined with increased fluid intake as a result of ecstasy-induced hyperthermia and dehydration, can dramatically change the normal concentration of the body's salts leading to drowsiness, nausea, seizures, and many other side effects. (CRAM Note: For more on hormone action see January's edition of Ask Dr. CRAM) Seizures may occur in some people, like the girl in the above scenario. The seizures may be secondary to some other factor, such as the low salt concentrations brought on by the water retention mentioned above. They may also be caused by impurities in the ecstasy pill, or ecstasy itself may directly cause them at normal doses or, more commonly, at higher doses.

Most overdoses are unintentional and can occur because the dose of MDMA present in pills is usually unknown and varies from dealer to dealer. So, it may be ecstasy when it is taken, but ending up in Emergency from taking the drug sure sounds more like agony!

Article first published April 14, 2006

Learn More!

Christophersen, AS. Amphetamine designer drugs - an overview and epidemiology. Toxicol Lett 2000; 112-113:127.

Gahlinger, PM. Club Drugs: MDMA, gamma-hydroxybutyrate (GBA), Rohypnol, Ketamine. Am fam physician 2004; 69: 2627.

Halpern, JH, Pope, HG Jr, Sherwood, AR, et al. Residual neuropsychological effects of illicit 3,4-methylenedioxymethamphetamine (MDMA) in individuals with minimal exposure to other drugs. Drug Alcohol Depend 2004; 75:135.

Morton, J. Ecstasy: Pharmacology and Neurotoxicity. Curr Opin Pharmacol 2005; 5:79.

Rattray, M. Ecstasy: Towards an understanding of the biochemical basis of the actions of MDMA. Essays Biochem 1991; 26:77.

Strote, J, Lee, JE, Wechsler, H. Increasing MDMA use among college students: results of a national survey. J Adolesc Health 2002; 30:64.

Peter Jennings - Ecstasy Rising (Video)

Dr. Barra obtained her medical degree at the University of Western Ontario and is currently completing her internal medicine residency in London, Ontario. She was born and raised in Toronto and loves gelato.

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