Commentaries

Addressing the Threats of MDMA (Ecstasy): Implications for School Health Professionals, Parents, and Community Members Ralph Wood, Linda B. Synovitz

se of “club drugs” threatens the well-being of school- U aged children, and therefore, school health profession- als and parents need to address this issue. The National Institute on Drug Abuse (NIDA) has increased funding to study the effects of club drugs and initiated partnerships with several national organizations to launch a multimedia campaign to educate teens and parents about the dangers of club drugs.’

The term “club drugs” is a broad category that includes illicit drugs such as LSD, Ketamine, GHB, Rohypnol, and MDMA (Ecstasy). The physiological effects of these drugs range from sensory distortion (LSD) and sedation (GHB, Ketamine, Rohypnol) to stimulation/sensory distortion (MDMA). These drugs are labeled “club drugs” because of their use at dance clubs and all-night dance parties known as “raves.”’

The designer drug, three, four methylenedioxmetharn- phetamine (MDMA), better known among its users as “Ecstasy,” is frequently the club drug choice among indi- viduals (ravers) attending raves because it is believed to enhance empathy and closeness, to be relatively safe, and have a long-duration of effect.’ Unfortunately, the safety of MDMA use has been overestimated. This article examines the prevalence of MDMA use by youth, the history and properties of MDMA, and the implications for school health educators and parents.

HI STORY MDMA, first synthesized in the early 1900s by German

chemists, was patented in 1914. The earliest use of MDMA was as an appetite suppressant for soldiers during World War Later, in the 1970s and early 1980s, MDMA was used therapeutically by psychotherapists to facilitate inter- personal relationships, increase self-esteem, and increase self-insight with patient^.^.^

In the early 1980s, MDMA became popular among recreational drug users, leading to an evaluation of the potential harmful effects. In 1985, MDMA was reclassified by the Drug Enforcement Administration as a Schedule I controlled substance, banning all production and use of MDMA therapeutically or otherwise. This reclassification

Ralph Wood, PhD, CHES, Assistant Professor, (rwood@selu.edu); and Linda B. Synovitz, PhD, RN, CHES, FASHA, Assistant Professor, (lsyn- ovitz@selu.edu); Dept. of Kinesiology arid Health Studies, Southeastern Louisiana University, SLU 10845. Hammond, LA 70403. This article was submitted May 22, 2000, and accepted for publication September 18, 2000.

was met with some resistance among physicians and psychotherapist^."^ In the late 1990s, MDMA use became synonymous with the rave and dance scene club culture and glamorized in popular music and film.’

PROPERTIES AND EFFECTS Properties

MDMA, most frequently referred to as Ecstasy, also may be known as Adam, XTC, Love Drug, and X . 2 Structurally, MDMA is similar to the naturally occurring hallucinogen, Mescaline, and synthetic methamphetainines, producing mild sensory distortion and central nervous stim- ulation, making this drug a more popular choice than tradi- tional hallucinogen^.^ Other synthetic drugs similar to MDMA include di-methoxy-methamphetamine (DOM), methylene-dioxy-amphetamine (MDA), and methylene- dioxy-ethylamphetarnine (MDE).4.5

The primary route of administration of MDMA is oral, typically in tablet or capsule form.) Other infrequent routes of administration include inhalation and injection. Typical doses of MDMA range from 110 to 150 mi1ligrams.l The cost for a tablet ranges from $10 to $30. The purity and potency of street MDMA varies, leading to concerns about dose level and possible

Short-Term Psychological and Physiological Effects The short-term effects of MDMA occur within 30 to 60

minutes of use, and the total effect time of the use of an average dose (120 mg) ranges from three to six hours. Frequently, users report feeling an initial “rush” of energy, which is common with stimulant use (eg, amphetamine^).'.^ After this immediate rush, users experience a plateau in the effects for approximately two to three hours and then a gradual decrease in the effects.6 After the effect has worn off, as with use of most stimulants, users experience exag- gerated feelings of fatigue4 (Figure 1).

MDMA users may experience several negative, short- term physiological and psychological effects. Physiological effects include elevated heart rate, insomnia, dehydration, dilated pupils, clenching of jaw, grinding of teeth, increase in body temperature, and elevated blood p r e s ~ u r e . ~ - ~ ~ ’ Psychological effects include poor concentration, inability to focus, paranoia, visual hallucinations, and Frequently, these stimulant effects are overlooked by users because of the feelings of euphoria and energy associated with MDMA

38 Journal of School Health January 2001, Vol. 71, No. 1

Perceived “positive” psychological effects have made MDMA a popular drug on the club scene and raves.’ These effects include an increased sense of well-being, greater empathy, heightened sensuality, and increased social inter- action.

Toxicity and Overdose A growing body of research is indicating that MDMA

use, even in small amounts, can result in severe acute toxic reaction~.~,~.~.’l Physiological symptoms of an MDMA over- dose include vomiting, heart palpitations, tachycardia, and hyperthe~~hia.~.’ Psychological symptoms of MDMA over- dose include panic reactions, anxiety, agitation, insomnia, and depres~ion . ’~~ Management of overdose reactions includes treating the individual for symptoms of heat exhaustion, dehydration, muscle cramping, seizure, and anxiety.

Figure 1 MDMA

3,4-Mentylenedioxymethamphetamine

Street Names: Ecstasy, XTC, Adam, X

Drug Classification: HallucinogenlStimulant-structurally similar to mescaline and methamphetamine.

Typical Use: Popular drug of use and abuse at dance clubs and raves, college campuses, and greater reported use in urban areas.

Route of Administration: Typically, oral in tablet or capsule form, infrequently inhaled or injected.

Typical Dose: 80 to 150 mgs.

Length of Effect: Immediate rush within first 60 minutes, 3 to 4 hour plateau period, followed by gradual decrease in effect, total time effect 3 to 6 hours.

Short-Term Effects: Physiological 1. Elevated heart rate 2. Insomnia 3. Dehydration 4. Dilated pupils 5. Clenching of jaw 6. Grinding of teeth 7. Increase in body

temperature 8. Elevated blood pressure

Psychological 1. Increased sense

of well -being 2. Increased empathy 3. Inability to focus 4. Visual hallucinations 5. Paranoia 6. Anxiety

Long-Term Effects: Verbal and visual memory impairment, possible permanent damage to neurons. Prenatal exposure produces an increased risk of birth defects.

Toxicity: Physiological Psychological 1. Vomiting 1. Anxiety 2. Tachycardia 2. Panic reactions 3. Hyperthermia 3. Agitation 4. Seizure 4. Depression

If you suspect that somebody maybe experiencing an overdose of MDMA, it is vital that you contact emergency medical services. The use of MDMA may cause an individual’s body temperature to become dangerously high - possibly resulting in death.

Researchers have linked deaths due to MDMA overdose to the hyperthennic effect of the MDMA may cause a drastic increase in core body temperature, sometimes soaring close to 110” F which can contribute to renal fai1u1-e.~ In addition, others have linked MDMA use to intracerebral hemorrhage, water intoxication, and liver damage. 8-11

long-Term Physiological Effects Few scientific studies have addressed the long-term

physiological and psychological effects of MDMA use. Researchers at Johns Hopkins University conducted a series of studies exploring the long-term effects of MDMA on rats and nonprimates.6.12 The results indicate that MDMA signif- icantly damages the brain nerve cells (neurons) which produce serotonin, a neurotransmitter. Serotonin influences mood, appetite, sleep, and memory.6.12 These studies also indicate that, in many cases, damaged neurons had regrown abnormally or failed to regrow at all. Based on these stud- ies, MDMA was found to selectively damage serotonin receptors in all specie^.^^'^^^^

In addition, when comparing individuals who reported (MDMA) use to individuals who reported nonuse, those reporting MDMA use experienced verbal and visual memory impairment.13 The higher the reported dose of MDMA, the greater the impairment.”

The MDMA user is not the only one who may be affected. A retrospective study exploring the relationship between prenatal MDMA use and birth defects indicated babies exposed to MDMA had a significantly increased risk of congenital birth defects, cardiovascular anomalies, and musculoskeletal anomalies.’4

In addition, early reports indicate that prolonged use of MDMA also may affect dopamine, a neurotransmitter responsible for motor control or dopamine receptors. As a result of its affect on dopamine or dopamine receptors, one study linked MDMA use to Parkinson-like symptoms in at least one user.15

PREVALENCE OF MDMA USE BY Y O U T H

National surveys note an increase in MDMA use over

Table1 Comparison of the Percentage

of High School Students Who Used “Other” Illegal Drugs (including MDMA)

, I

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the past several years. The Monitoring the Future Survey (MTFS), conducted under a series of researcher-initiated grants from the National Institute of Drug Abuse,I6 exam- ines the frequency of alcohol and drug use among US high school students. The 1999 MTFS revealed MDMA use among high school sophomores and seniors continued to rise in the past three years. For seniors, lifetime prevalence of MDMA use rose from 5.8% to 8.0%, a 2.3% increase.16

The Youth Risk Behavior Surveillance Survey (YRBSS), conducted by the Centers for Disease Control and Prevention, includes national, state, territorial, and local school-based surveys of high school students. The 1997 YRBSS was conducted from February 1997 to May 1997. At the national level, more than 16,200 students were surveyed with the national sample comprised of an approxi- mate equal number of students in grades 9 (23.6%), 10 (23.9%), 11 (25.2%), and 12 (27.2%).17 From 1991 to 1997, use of MDMA, heroin, stimulants, methamphetamine, and LSD increased 1.4%ls (Table 1). In addition, Ecstasy was implicated in the death of several youth in the United Kingdom and United States.*-’O

THE RAVE SCENE MDMA use is closely tied to the rave scene.*,’ The term

rave is used to describe an all night dance party, typically held i n large dance halls. This phenomenon began in England in the early 1990s and quickly became common in the United States.2 Raves are associated with loud, repeti- tive, electronic music called “Techno” and commonly start late in the evening and last until dawn. The stimulant effects of MDMA allow the raver to dance most of the e~ening.~,’

The Community Epidemiological Work Group (CEWG), a research branch of the National Institute of Drug Abuse, reports that MDMA use is closely related to the rave scene in several large metropolitan areas including Boston, Chicago, Miami, Minneapolis/St. Paul, New Orleans, New York City, Phoenix, Seattle, and Texas.I9 In addition, the CEWG reports MDMA use is increasing outside the rave, dance, and club scenes.I9

IMPLICATIONS FOR SCHOOL HEALTH PROFESSIONALS A N D PARENTS

Become Knowledgeable Based on the most recent statistics from the Monitoring

the Future Survey and the YRBSS, school health profes- sionals and parents should expect MDMA use to increase among students. To address this problem, school health professionals and parents should listen for slang-terms and become familiar with their meaning. Students may refer to MDMA as Ecstasy, XTC, Rave, E, M, bean, roll, or X. These terms may be heard in student conversations or found on student notebooks and backpacks. In addition, several new “pop” films geared toward teen-agers have included scenes of MDMA use. Most recently, the motion picture “GO” centered on purchasing and using MDMA. Since use of MDMA and other dangerous designer drugs (GHB, rohypnol, ketamine, and LSD) frequently occur at raves, school health professionals and parents should become familiar with the latest trends in the adolescent substance use culture.

If school communities believe a drug problem may exist, a needs assessment should be conducted. Students should

complete a drug use survey, and interviews with students, parents, teachers, psychological/counseling services, and law enforcement personnel via focus groups could result in obtaining more information about potential teen-age drug use and abuse problems. Not only is it important to ascer- tain if youth are using drugs such as MDMA, it is important to learn why.

Online Resources Several online government and independent supported

resource sites are available to school health professionals and parents desiring more information about MDMA or other designer drugs.

Government Supported Sites. Government sites provide considerable information about current patterns of drug use in the United States, as well as current drug and alcohol abuse prevention strategies. Of particular interest are the drug and alcohol fact sheets, which provide basic, essential information about substances of use and abuse. Contact: w w w. health.org; w w w.drugfreeamerica.org; or w w w.club- drugs.org.

Independent Sites. Independent sites provide a variety of information about MDMA and other recreational drugs. These sites, while geared toward the substance user, also may provide school health professionals with valuable information. The site, www.erowid.org/psychoactives/ psychoactives.shtm1, operated by a nonprofit organization, contains information about substances of use and abuse, including incidence and prevalence data and substance users’ experiences. The site also includes links to scientific research on recreational drugs, including articles published in scholarly journals. The mission of the not-for-profit site www.ecstasy.org is to gather objective and up-to-date infor- mation about MDMA. The site contains various articles from scientific journals and the popular media. In addition, the site also includes Ecstasy users’ experiences with the drug.

Dispel Myths School health professionals and parents must dispel the

myths associated with MDMA use. Talking points should emphasize the following:

MDMA is not a harmless drug. Street MDMA is a man-made drug that is frequently

MDMA use can cause the user’s body temperature to

Taking MDMA may prove fatal.

impure.

become dangerously high.

SUGGESTIONS FOR COORDINATED SCHOOL HEALTH PROGRAMS Health Instruction

To address the MDMA threat, school health educators could include special units of instruction focusing on the risks associated with use of club drugs, particularly Ecstasy. Most importantly, psychosocial skills training, the most important component of any drug education program should be implemented. These skills should include: deci- sion-making, problem solving, self-concept/self-esteem building, assertiveness, resistance, and stress management. To increase awareness of health risks from MDMA use, school health educators could plan and implement drug

40 Journal of School Health January 2001, Vol. 71, No. 1

education seminars for parents, other school professionals, and community members.20~21

Physical Education Physical educators can monitor student conversations in

the locker room, as well as monitor student behavior during physical activity exercises, paying special attention to any student who seem to be exhibiting “more energy” than normal as this might be an indication of MDMA or other stimulant use.22

School Health Services School nurses should become familiar with the short-

term effects, particularly the signs and symptoms of an overdose. Since they may serve as the first contact for a young person experiencing the negative effects of Ecstasy. In addition, school nurses can collaborate with school health educators and counselors to provide inservice programs for other faculty and ~taff.~’

School Counseling Services School counselors should monitor changes in student

grades, behavior, and mood. Frequently, these are early indicators that youth may be using substances. In addition, the school counselor serves as a confidant to students. This position provides the counselor a unique opportunity to monitor changes in the adolescent subculture within the S C ~ O O ~ . ~ ~ . ~ ~

Healthy School Environment A healthy school environment is an essential protective

against the initiation and use of substances. All school health professionals can collaborate to initiate social marketing campaigns to educate students about the risks associated with substance use, as well as provide students opportunities to increase personal and social skills.26

Family and Community Involvement Several avenues exist for collaboration between school

health professionals, families, and community members to address the issues of Ecstasy use. The police department can monitor the frequencies of drug arrests related to Ecstasy use and raves. Collaboration with local substance abuse treatment professionals can provide useful informa- tion such as prevalence, age groups involved, and “best practice” intervention strategies. Substance abuse treatment professionals can also serve as guest speakers for health education classes or assemblies. Occasionally, treatment professionals could arrange to have youth who are partici- pating in substance abuse treatment, come voluntarily to schools to relate their personal stories.

Families can become more informed and aware. A parent network can be established among parents to educate one another and share information about rave sites. In addi- tion, parents can provide opportunities for their children, as well as their children’s friends to participate in supervised, substance-free a~t ivi t ies .~~

Youth using MDMA place themselves at physical and psychological risk. With increased awareness, schools, parents, and community partners can do much to alleviate this growing health concern.

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new national education -and prevention initiative by NIDA and national partners, December 2, 1999. NIDA News Release. 1999: 1-2.

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