E is for Ecstasy, Chapter 6

[Contents]
[Chapter 5][Chapter 7]

E for Ecstasy by Nicholas Saunders

Chapter 6: The dangers of Ecstasy

For more recent information on this topic, see Ecstasy Dangers, The Ecstasy Toxicity Debate, Pathology Paper, Psychological Dangers and Research in the USA on my site ecstasy.org online in both North America and Europe

The most likely danger from taking Ecstasy is consuming something else instead. In Manchester in the summer of 1993, all 13 tablets and capsules bought as Ecstasy turned out to be other drugs.(172) Some people have taken "Ecstasy" several times have never actually had MDMA. Although the quality was said to be improving during 1993-4, you can never be sure what you are getting unless it is from a batch that you know is good. Even dealers often have no idea what they are selling, and may not even know that "Ecstasy" means MDMA and nothing else.(175) See Chapter 12 under Is it really Ecstasy.

What follows relates to MDMA.

There are several distinct ways in which MDMA can be dangerous, and as this is a very important issue, I want to look at each in turn. These can be divided into immediate, short term and long term medical dangers and psychological dangers, giving four categories. There is also the question of addiction.(12)

Immediate medical dangers

There have been frequent stories in the press about people who have died from taking Ecstasy in Britain, and several cases are reported in the medical journals. By July 1992 The British Medical Journal was claiming "at least seven deaths and severe adverse reactions have followed its use as a dance drug." Dr. John Henry of the National Poisons Unit (attached to Guy's Hospital, London), who studied MDMA-related deaths in the period 1990 and 1991, found the cause to be heat stroke in every case. All the fatalities occurred at crowded parties and clubs where "sustained physical activity, high ambient temperature, inadequate fluid replacement can all reduce heat loss and the direct effect of the drug may upset the thermoregulatory mechanism."(51) By March 1993, the National Poisons Unit listed 14 deaths among people in whom MDMA was detected; 13 showed symptoms of overheating and one of asthma.(52) Fortunately, with widespread knowledge about the danger of overheating and how to avoid it, this cause of death has been nearly eliminated, while in America it is as yet unknown.(161)

In the United States, where the drug has been widespread for far longer, very few deaths have been reported and none of them are believed to be due to heatstroke. A study of five deaths associated with MDMA in the US showed that there were other probable primary causes of death in four of the cases, while the cause in the fifth case was not established. The report suggested that "people with cardiac disease may be predisposed to sudden death by taking MDMA."(53) The implication is that, rather than being toxic in itself, the drug made the users more vulnerable to preexisting conditions such as a weak heart. No cases of death due to overheating have been reported in the US.

Some people have attempted to explain this discrepancy by suggesting that poisonous additives may be the cause of death in Britain. However, this is not born out by Dr. Henry's studies or by samples analysed for the police.(54)

Overheating

The most likely explanation is the way the drug is used: in Britain people often take Ecstasy while dancing for hours on end in very hot, humid raves without sufficient drinking water. The conditions at some raves could cause heatstroke even without a drug.(55) It has been suggested that a few individuals are particularly vulnerable to heatstroke, possibly because they have a tendency to develop a high temperature(56), though it is more likely that the conditions are to blame.(170)

Heatstroke is a well-known cause of death, but in other situations it only affects people who are pushing themselves to the limit(16) or are unable to escape from the heat. What is peculiar about Ecstasy-related deaths is that the victims appear to make no real attempt to cool down. This has been explained by ravers being in a trancelike state, but experiments with rats and mice show that overheating may be a more direct effect of the drug.(57) Researchers have examined the way rats respond to Ecstasy in very hot conditions. Without MDMA, the rats did their best to cool down by becoming less active and losing heat through their tails. But on MDMA they became more active and did not attempt to lose heat - as though they had lost the sense of being too hot - until they died of heatstroke. Similarly, rats in a cold environment made no attempt to keep warm when on MDMA. Experiments on mice show that MDMA is five times more toxic in crowded conditions than in isolation.(10, 12) This may help to explain why ravers die of heat exhaustion.

So how does overheating kill someone? Our body temperature (like that of other mammals) has to be controlled very precisely for us to function, which is why we use a thermometer to indicate when we are ill. If we get too hot, above 42 degrees C (108 degrees F), our blood starts to form tiny clots that stick to the artery walls. This is not usually a problem in itself, but the process uses up the clotting agent in the blood, so that there is nothing to prevent bleeding. There are always tiny cuts and scratches inside the body and brain which are due to the body constantly replacing worn out tissue with new cells, and normally these leaks are blocked by the clotting of blood so that you don't even notice them. But above 42 degrees bleeding is unfettered, and this is made worse by high blood pressure due to the speedy effect of MDMA and exercise. People can bleed to death in this way, and if bleeding occurs in the brain it can cause a stroke. When someone is bleeding internally, blood may run out of their mouth or anus.(30)

There are other ways of dying through taking Ecstasy, but they are unlikely to happen to normal healthy people. On MDMA, we can be more active without feeling pain or exhaustion; our temperature, sweating, blood pressure and pulse increase without the normal warning signs of feeling discomfort or exhaustion. It is not surprising that there have been cases of people with weak hearts or other medical conditions have died on MDMA, although there is no known reason why the use of MDMA should particularly affect asthmatics.(58) There is also a well-documented case in America of a healthy woman who took MDMA and nearly died for no apparent reason, implying that certain individuals may react in extreme ways.(59) Research suggests that some one in 12 people may be particularly sensitive to the drug for genetic reasons.(178)

Other adverse effects that have been reported in the press - such as chest pain, confusion, memory loss and being unable to stand up - often originate from staff working in the casualty departments of hospitals. However, one doctor told me that he believes that drug users tend to say they've taken Ecstasy when they ask for medical help because they believe they will receive more sympathy, yet their symptoms often imply they have taken another drug.

In addition, a possible minor danger has been suggested, that MDMA use liberates 'oxygen free radicals'. These are normal in small quantities, and the body has a protective system for controlling their level, but large amounts may overwhelm the system and contribute to fatigue and 'mental dysfunction associated with sustained amphetamine abuse'. The problem can be solved by taking vitamins: 2-4 grams of vitamin C and 1,000 IU of vitamin E along with the drug, or treble these quantities to treat the effects afterwards.(36)

Medium term medical dangers

In 1982 there were several reports of people who had contracted hepatitis or jaundice (both diseases of the liver) after taking MDMA several times(60); kidney damage has also been suggested.(30) The reports are based on the opinions of doctors without investigation or research, so they should be taken as potential rather than as established dangers. It is not known whether the diseases were caused by consumption of alcohol or other drugs(55), or whether the patients had weak kidneys or livers to start with. None of the cases were fatal. Such damage is not found in animal studies, and there have been no such cases reported in the US. The explanation may be that such damage was caused by a contaminant in a bad batch rather than the drug itself(127) , or that the kidneys were effected by dehydration.(200) There are, however, worries that Ecstasy may be harmful when taken with alcohol(62, 60) or amphetamine.(141)

Long term psychological effects

One of the worst fears about Ecstasy is that it may be causing permanent brain damage to users without them being aware of it. It has been suggested that the drug destroys nerve endings or synapses(73), and that eventually users will suffer from depression and senile dementia - the loss of memory and confusion that affects some old people - but at a much earlier age. These fears have not been established. The most damning evidence concluded from a trial is that heavy MDMA users probably had slightly worse short-term memories, but were not depressed nor did they show any other problems that might effect their lives.(156) In another trial, the researchers discovered to their surprise that long term MDMA users scored better than non-users: they were "less impulsive, more harm-avoidant, and have decreased indirect hostility".(157) [More on this trial below under brain damage.]

Some people argue that damage may not show until old age. Serotonin levels decline with age, so MDMA use would exaggerate this decline. This assumes that some negative aspects of old age are linked to lower serotonin, but there is no evidence to support this hypothesis, such as MDMA having an adverse effect on old people.

Long term brain damage

Evidence that MDMA causes brain damage is based on experiments with animals, mainly rats, although mice, dogs and apes have also been used. After the animal has been given the drug, it is killed and its brain sliced into sections for examination. Because there are billions of brain cells and they are very small, damage may be difficult to see, so various indirect methods have been developed to indicate whether and where damage has occurred.

The method most commonly used, because it is easiest, is to check the level of serotonin (5HT) within the brain cells and nerves several weeks or months after MDMA is administered. This is done by cutting out a section of the brain, extracting the serotonin and measuring it. Many prescription drugs lower serotonin temporarily. However, if the serotonin level fails to return to normal, it is inferred that the cells have been damaged and have allowed serotonin to escape. When serotonin levels take a long time to return to normal, this was interpreted as meaning that the brain was damaged but gradually repaired itself.(63)

Many trials deduced that MDMA was toxic because large doses lowered rats' serotonin levels. Also, researchers gave monkeys MDMA and found that their serotonin level was never completely restored, so assumed the monkeys' brains were permanently damaged, and this led to concern that the brains of humans may also be damaged.(63) The doses given were somewhat larger than normally used, but the effect of MDMA does vary according to the species(64) and humans tend to be more sensitive than animals.

News of this brain damage to animals caused a scare and contributed to MDMA being classified among the most dangerous drugs, but over the years doubts have grown as to whether the results were valid because this observed physical damage was not matched by psychiatric damage. There has not been a single confirmed case in the scientific literature which conclusively links MDMA neurotoxicity with behavioural or functional consequences; there is no evidence of damage in psychological tests on MDMA users, and no damage has been observed by psychiatrists using the drug on patients.(69, 70, 141)

In 1993, a chance discovery showed that much of the evidence about MDMA causing brain damage was based on a false assumption. Dr. James O'Callaghan, while trying to establish a standard way of measuring neurotoxicity, needed some rats whose brains had damaged cells, so he gave them MDMA. But, to his surprise, their brain cells were not damaged unless he gave them really enormous doses (over 30 mg/kg, the equivalent of taking 20 Es), twice daily for a week! He then looked into the previous work which showed nerve endings to be damaged by quite moderate doses, and discovered that the results were flawed. Instead of actually observing the damage, which involves a laborious procedure called 'silver staining', the scientists had made an assumption which turned out to be wrong: that a change in the amount of serotonin in the brain indicates damage. This assumption was made on the grounds that serotonin exists within brain cells, and that a reduction would occur if the cells were damaged. "It's rather like a hose pipe full of water," explained a researcher, "the scientists found it contained less water, so they jumped to the conclusion that the pipe was leaking without actually finding the damage".(71) Another research project showed that the toxicity of MDMA on rats depends on the type of cage they are kept in, casting further doubt on previous research.(177)

However, in 1994, the results of a 5-year research project on humans was published indicating permanent brain damage in people who consumed large, but not unusual, amounts of MDMA for several years.(157) The methods used were again indirect and although unsupported, must be taken seriously. Apes were given various doses of MDMA and their spinal fluid was examined, then they were killed and their brains examined for damage. By this method the researchers found 'markers' for brain damage in spinal fluid. Assuming similarity between humans and apes, the spinal fluid of MDMA users indicated that their brain cells that produce serotonin had died back. In apes, most of these grew again, but did not produce as much serotonin. The researchers then looked for signs of damage to those with supposedly damaged brains through psychological tests, but to their surprise found that MDMA users actually did better than non-users! In the media this was either ignored or passed off as due to people with milder personalities gravitating towards MDMA in the first place.

Other researchers have criticised the conclusion that there was physical damage caused, saying that the assumption about spinal fluid indicating damage was not justified. Also, there is an alternative explanation: that the MDMA users had lower serotonin levels in the first place and that no damage was caused. In conclusion, although there is strong evidence that MDMA is physically neurotoxic(143), any damage caused to the brain does not appear to affect its function negatively, the only evidence so far being that the change is beneficial.(194)

Other evidence that the damage to serotonin-producing brain cells is unlikely to harm the brain's function is that the drug fenfluramine, which causes similar damage to MDMA has been used as a prescription drug for many years without reports of harmful side effects.(26, 64, 65, 66, 70, 137, 141, 154, 157)

Quite apart from physical damage to brain cells, another cause of concern is that constantly lowered serotonin levels may eventually cause psychiatric problems such as depression. However, drugs of the SSRI (Selective Serotonin Reuptake Inhibitor) type such as Prozac (fluoxetine)(47, 137, 148), now widely prescribed as mood elevators, also cause long term reduction in serotonin levels and are considered harmless.(30, 67, 68, 137)

This is not evidence that Ecstasy is safe; only that some (widely publicised) evidence against it is unreliable. My conclusion is that using a lot of MDMA for many years probably does damage brain cells, but without causing psychiatric problems and may actually have benefits. However, even if the effects appear beneficial, there is obviously a risk in making any permanent changes to one's brain, especially when the process is not fully understood.

Contaminants

Another danger is that what you bought as E is mixed with a poison of some kind, or an addictive drug like heroin. Although this is a possibility, it doesn't appear to happen. Dr. John Henry of the National Poisons Unit looks for poisons in the blood and urine of people who have died or are seriously ill after taking drugs, and says he has not come across any such cases.(51) However, he has come across Paracetamol, Codeine, Amphetamine, MDA, MDEA, Ketamine, Tiletamine and LSD.(152) Dr. Les King, who analyses suspected drugs seized by the police at the Aldermaston forensic laboratory has never come across (or even heard of) poisonous additives to Ecstasy, although he does not specifically test for them.(54)

In Holland, where the government has a far more liberal attitude, people are employed to buy drugs sold on the street in Amsterdam. They are analysed and the results are then made public. Once again, poisons and addictive drugs have not been found mixed with drugs sold as Ecstasy.(21)

So why do these rumours persist? Much of the Ecstasy sold is not MDMA(172, 175) so that users get a different effect than they expected. Also, many users are unaware that even pure MDMA can have unpleasant effects in some situations. Most users just want to have a good time and don't believe they have any psychological problems, so it is more acceptable to explain unpleasant experiences as being due to poisons. They report a terrible headache "like rat poison"; the media report it as being rat poison and other users believe it.

Psychological dangers

For more recent information on this topic, see Psychological Dangers of Ecstasy on my site ecstasy.org online in both North America and Europe

In my opinion, there is a far greater risk of damaging the mind than of damaging the body through taking MDMA. While scientists argue about whether there is any evidence of physical damage, instances of mental damage are easy to find. Just as I have witnessed people whose lives appear to have been enriched by MDMA, there are others whose lives have got worse, if not actually been ruined as the tabloid papers would have it. Ecstasy has a profound effect on many people, and this is not always for the better. People may be pushed into taking Ecstasy by peer group pressure, and be made to feel inferior if they do not enjoy it. For instance, some people will claim that Ecstasy can do nothing but to bring out your true personality by removing 'blocks' or defences. While this may be true in a sense, there are many perfectly sane people who do not feel liberated by taking MDMA, and, for whatever reason, they do not enjoy it.

There are also those who do enjoy the drug but suffer from the psychological effects. Very often this is from taking too much too often, resulting in paranoia and depression. Others simply find that everyday life is boring by comparison, and lose motivation.

It is difficult to identify these dangers without further research, as there are always other factors involved with psychological problems, for instance other drugs. The stories I have heard about people whose lives have been 'screwed up' by Ecstasy have always involved taking large amounts or taking other drugs as well. In addition, there are the stories of first time users who have 'flipped'; I don't know of any personally, but it seems likely that these were unstable personalities. More research is needed; the results could prevent mishaps in the future.

Addiction

A drug is considered addictive if physical withdrawal symptoms occur when a regular user stops taking it. MDMA is not addictive by this definition, and in fact has a built-in barrier against frequent regular use - it rapidly produces tolerance while providing more side effects.(34) Whereas you can get drunk every night on alcohol, MDMA soon ceases to work. The pleasant effects become less and less, and after less than a week's daily use of MDMA they disappear completely while the amphetamine-like effects increase.(37) It is then necessary to stop taking MDMA for several days before you feel good on it again, and to get the full effect may take several weeks. Frequent use is almost unknown in the States, where Ecstasy has been noted as unique among recreational drugs in that it is not taken repeatedly.(69) However, many British users do, in fact, take MDMA every weekend and try to overcome tolerance by increased doses while putting up with the poor quality of the effects.

There are many regular users who rely on Ecstasy to make them feel good, and who feel depressed and lacking in motivation except while enjoying its effects. Others simply find that life is dull except when they are on it. I have even heard of a man who can only function normally when he is on Ecstasy.(75)

Most hard drug users do not like Ecstasy.(76) However, the Drug Enforcement Administration in the US carried out experiments which they interpreted as indicating potential for abuse: they found that cocaine-addicted monkeys would 'reinforce themselves with MDMA'.(12, 141)

Overdosing

The effect of taking several Es at once is to produce an amphetamine-like effect - "a jittery, anxiety-provoking high".(5) Some users take Ecstasy specifically to achieve this sort of effect, but they are said to be switching to amphetamines.(13) It is likely that taking large and frequent doses is bad for you(77), although one man is said to have taken 42 tablets yet only suffered a hangover(51), and a personal account is included of a woman who says she survived taking 100 at once.(appendix 2) Ecstasy and amphetamine are more toxic when taken together.(180)

Although there is no specific evidence that overdoses cause permanent damage, there is certainly a high risk that they do.(12, 63, 74) This may be reduced by taking fluoxetine (Prozac)(147, 148, 176), even several hours afterwards and perhaps also by taking vitamins.(36)

For medical treatment see reference (180) (or ring the National Poisons Unit on +44 (0)71-955 5000)

Does Ecstasy use lead on to other drugs?

Ecstasy and opiates have little in common, hence junkies do not find that MDMA satisfies their needs.(76) Social workers with a broad experience of drug users believe that it is unlikely that MDMA users will go on to addictive drugs because junkies are a separate social group.(42) Rather than being regarded as romantic antiheroes, the typical Ecstasy user sees them as "old and smelly"(78), and is strongly anti-heroin.(79) However, MDMA has been referred as a 'gateway' drug to the hallucinogens(135), and there is some evidence to this effect.(26, 40) One user has suggested that 2CB forms a bridge for Ecstasy users to cross over into the world of psychedelics.(138) Besides, Ecstasy users do generally take other drugs, especially amphetamine, LSD and cannabis.(78)

Risk of death

For comparisons with horse riding and fishing, see Ecstasy Dangers my site ecstasy.org online in both North America and Europe

There are two ways of looking at the risk of death from taking a drug. The first is to compare the total number of people who have died with the total number of doses taken. This gives you the risk of death per dose, such as one in a million.

The second is to compare the number of people who have died in a year with the number of people who consume the drug. This gives the risk of death per year as a result of taking the drug.

In both cases, two figures are needed: the number of people taking the drug and the number of deaths resulting. These are examined below.

How many deaths are due to Ecstasy?

Surprisingly, this is not easy to answer. The official British Home Office figures are so out of date as to be useless, although officials guess that the present total figure is somewhere between 10 and 20.(80, 81)

The National Poisons Unit put the present figure of known confirmed Ecstasy-related deaths at 14 for the period January 1988 to July 1992.(52) These are fatal cases where MDMA was found in the victim's blood or urine, but it is not necessarily implied that MDMA was the cause of death. Their list is not comprehensive.

Newspaper reports up to March 1993 blame Ecstasy for the death of 17 to 22 people(82), but these figures cannot be trusted. The main reason is that 'Ecstasy-related death' is often mistakenly taken as meaning that MDMA was the cause of death, rather than that the victim was known to have taken MDMA but the cause had not been established. Even the 'quality' newspapers and medical journals cannot be trusted (see chapter 7).

In the USA, an examination of the deaths of five people who had taken Ecstasy showed that other potentially lethal medical factors played a major part. Although MDMA was found in the victims' blood when they died and may have contributed to their death in some unknown or indirect way, in four cases there was an explanation for their death which was not related to taking MDMA.(53) The fifth death may also have been due to other causes.(26)

An organisation called DAWN (Drug Abuse Warning Network, part of the National Institute of Drug Abuse) collects reports of illicit drug use from hospital casualty departments all over the United States.(22) Whenever someone turns up at an emergency room and a drug is involved, either found on the person or in their blood or urine, or even if a patient comes in with a problem and mentions that it is drug-related, a report is sent to DAWN besides reports from postmortem examinations when drugs have been detected. These reports are analysed and figures are published for all drugs that are reported over 200 times in the past year. Although 138 drugs are listed, Ecstasy has never been included. DAWN publishes a separate list of drugs that have caused more than 10 deaths, but again Ecstasy is not included. The figures imply that there is no general medical cause for concern over MDMA use: though there are mishaps, these are rare. Indeed, there are well over a hundred other drugs that cause more problems. Even if the number of problems due to MDMA were increased in proportion to usage in Britain, there would still not be a significant number.

In conclusion, it seems likely that, apart from very rare incidents, the deaths in Britain as a consequence of taking MDMA is limited to those who died of heat stroke, of which 14 cases are known to date. The worst annual figure was that for 1991 with seven confirmed Ecstasy-related deaths known to The National Poisons Unit.(52)

The number of people in the UK who take Ecstasy has been discussed in Chapter 5. An educated guess is that the number lies between one and five million. How often users take the drug is also open to guesswork. A London survey showed that a third of users took Ecstasy at least once a week, while a minority binged on 10-20 over a weekend. This would imply that average usage among this sample was somewhere in the region of 25 a year, although this may not be typical.

Taking the worst figure of seven deaths in 1991 and assuming there were only 1 million users, the risk of dying from using Ecstasy would have been 7 in a million or 1 in 143,000 per year. If users take an average of 25 Es a year, then the risk of death on each occasion is 7 in 25 million or 1 in 3.6 million.

To put this into perspective, if you take five rides at a fun fair you run a risk of 1 in 3.2 million of being killed through an accident.(83) Some sports are obviously dangerous, such as parachuting which kills 3 in 1000 participants per year. Even skiing in Switzerland is risky - 1 in 500,000 are killed.(84) If you play soccer, every year you run a risk of 1 in 25,000 of being killed. But if you stay at home instead of going out you still aren't safe, since the risk of being killed through an accident at home is 1 in 26,000 a year!(16)

Many prescription drugs carry a high risk, including some you can buy over the counter without prescription. For example, over 200 people die from taking Paracetamol in Britain each year, more than ten times as many as die from MDMA.(30, 162)

Many people will argue that these figures are meaningless as they are based on guessed statistics. Suppose the figures distort the results ten times over, the risk of dying through taking Ecstasy is still smaller than taking part in a wide range of acceptable activities. It has been said that more people would die if alcoholic drinks replaced Ecstasy at raves.(55) Moreover, if ravers and organisers took the appropriate steps to avoid overheating the risk would be negligible.

Permanent damage to health

It is often argued that MDMA has never undergone the rigorous trials demanded of a prescription drug, and therefore carries more risk. The counter argument is that MDMA has been tested by many millions of people over the past twenty years, and that this is a far more stringent trial. It is true this has been done in an indiscriminate way and without controlled conditions, but with such an enormous sample, evidence should have come to light by now if the substance is toxic. Since it has not, it seems fair to conclude that, although there may be unknown damage caused, the risk is no greater than taking a new prescription drug.

Temporary damage to health

Taking Ecstasy often causes fatigue simply because of the increased metabolic rate - the body and mind 'live faster' and you wear yourself out. To this must be added fatigue caused by whatever you are doing on E, such as missing a night's sleep, dancing for hours on end and not eating. Taking booster doses or any other drugs cause extra fatigue(62), and the exhaustion due to two drugs taken together may be greater than adding the effects of taking the drugs separately. Again, for people who are not healthy this extra exhaustion could affect them badly, and for someone on the verge of being ill this might be the 'straw that breaks the camel's back'. There are also indirect dangers of taking Ecstasy. These include taking something else you thought was MDMA and taking depressant drugs to reduce the effects of taking 'too much too often'.(77)

One study has put the risk of ending up in the casualty department of a hospital at 23 per 100,000 rave attendances. The majority of the sample studied discharged themselves after being given treatment for racing hearts. None of those who had taken Ecstasy alone needed further treatment, the rest having taken a variety of other drugs at the same time.(85) This compares to the risk of injury while on a skiing holiday in Switzerland, which is 3% or 3,000 per 100,000.(84)

Catching colds and other infections

It's often said that taking Ecstasy affects your immune system, making you more likely to catch a cold afterwards. I have not found any evidence to support this, but it is common medical knowledge that you are more vulnerable to disease when you are exhausted, and that a hot sweaty environment is ideal for transmitting viral infections.(40) Add to this that many people make skin contact while on Ecstasy, and it is not hard to see that while MDMA may not directly affect the immune system, its use drains one's reserve of energy and this may indirectly make you more susceptible to colds and other infections.

Social dangers

A very real danger of taking Ecstasy is that you may do or say something you will regret, or that will upset someone else. This may be trivial, such as embarrassing some member of the public by your lack of inhibitions, or as serious as causing an irreparable rift; for instance, by telling your father that you have never respected him. There is also "a tendency to call up ex-lovers and casual acquaintances and tell them how much you love them".(7) Another danger is 'inappropriate emotional bonding', by which is meant falling in love with the person you are with,(43) although the same source also claims that "whatever you choose to create will be a perfect and appropriate choice." Acting on impulse while under the influence can also be a mistake - although insights can be made on Ecstasy, so can mistakes.(86) A quite different kind of danger is that using Ecstasy makes people into criminals just as happened with drinkers under Prohibition in the USA, and reduces their respect for the law.(77, 13)