Ecstasy (MDMA) Dependence
ecstasy.org note: this paper may be very useful for those who
are arrested with a few pills and are automatically charged with 'intent
to supply'. It demonstrates that individuals might possess quite a number
of pills which are genuinely for their own consumption.
ECSTASY (MDMA) DEPENDENCE
Karl L. R. Jansen
Published as: Jansen, K.L.R. (1999) Ecstasy (MDMA) Dependence. Drug and
Alcohol Dependence; 53/2, 121-124.
Dr. Karl Jansen The Chaucer Centre 13 Ann Moss Way (Off Lower Road) London
MDMA is generally described as non-addictive. However, this report describes
3 cases in which criteria for dependence were met. A wider understanding
that MDMA can be addictive in rare cases is important as very heavy use
may cause lasting neuronal changes. This risk could be reduced with effective
identification and treatment of dependent persons. In one case dependence
was linked with self-medication of post-traumatic stress disorder (PTSD).
Addiction, amphetamine, dependence, Ecstasy, methylenedioxymethamphetamine
(MDMA), post-traumatic stress disorder (PTSD).
1. Introduction and Methods
MDMA (methylenedioxymethamphetamine) is described as non-addictive, as
was amphetamine itself earlier this century: "there are simply no reports
on individuals who take frequent and large amounts of MDMA for an extended
period of time" (Peroutka, 1990). However, there are now reports of
individuals who have used large quantities for extended periods (McGuire
and Fahy, 1991). These reports usually focus on adverse effects and rarely
consider dependence as a specific issue. These 3 cases indicate that MDMA
can be addictive in certain cases. Identification and treatment is important
as there is some evidence to suggest that high intensity MDMA use may cause
lasting changes to serotonergic nerve terminals (McCann et al., 1996; Ricuarte
et al., 1988).
Case A: A 19 year old nightclub promoter (A) was seen 2 weeks after having
a seizure, following the use of 20-40 MDMA tablets, and about 1gram/24 hours
of amphetamine sulphate powder, every week-end for a year. He had first
taken MDMA and amphetamine at the age of 17, initially taking 1 or 2 pills
in the weekend at parties. This pattern remained relatively constant for
the first year. At the age of 18, his use of both drugs increased in association
with increased income and greater social involvement with clubs and parties.
He would take 5 - 10 pills of MDMA in a typical weekend, and about half
a gram of amphetamine sulphate powder (in total) either wrapped in tissue
paper and swallowed, or via the intra-nasal route. The amphetamine was often
taken before actually leaving the house to go out for the week-end, while
MDMA pills were more likely to be taken when at the venue.
A large increase in the use of both drugs ocurred when he became employed
in nightclub promotion at the age of 18. The usual pattern of use was to
commence consumption on Thursday night and to continue in a binge pattern
until the early hours of Monday morning, often staying awake almost continuously
for much of the period (described as an eighty hour weekend), with attendance
at breakfast clubs following night-clubs. The rest of the week was usually
spent recovering. His mood would often be quite low by Wednesday. He experienced
significant weight loss and often felt very weak.
By the age of 19, he spent almost his entire disposable income on MDMA
and amphetamine (oral and intranasal routes only), and was also given large
quantities of these and other drugs (cocaine and cannabis) by dealers who
wished to gain entry to clubs and other persons who wished to be placed
on the guest list. He used about 5 grams of cocaine per month. He said that
he would use cocaine daily if he had an unlimited supply, but would not
buy it. There was little clear division between his employment and recreation.
The two activities were largely merged with each other, the drug use being
equally involved in both.
Despite the seizure, he was unable to stop using MDMA and amphetamine
without external assistance. He described tolerance, and extreme fatigue
and low mood after stopping use.
His father was alcohol dependent and described as violent. His father's
behaviour created an unpleasant childhood with high anxiety levels. His
left school at 16 without qualifications. His relationships with women were
shortlived, and there was evidence of a high level of impulsivity. He denied
any other criminal, medical or psychiatric history. There was no personal
or family history of epilepsy. He smoked cannabis almost daily, sometimes
used temazepam to sleep, smoked 20 cigarettes per day, drank about 15 units
of alcohol weekly, and very rarely took LSD and other hallucinogens. He
had not used heroin.
Case B: A 30 year old male (B) gained access to a large supply of pure
MDMA powder. For 6 months he injected 250mg of MDMA, intravenously, up to
4 times daily neglecting non-drug related activities. He was also injecting
heroin and related opioids, and was dependent on benzodiazepines. His general
pattern of drug use was to take whatever drugs were available to him, including
alcohol, in large quantities. He had a particular preference for the intravenous
route regardless of the drug in question. For example, he had injected fluoxetine
He had first taken MDMA 10 years earlier, at the beginning of the English
rave culture, at the free parties which took place during this period. At
that time, his supplies of MDMA were limited, as were his finances, and
he thus took only took 1-2 pills on occasional weekends. He preferred to
spend his money on opiates. This remained the usual pattern for at least
8 years, although he would take up to 10 MDMA pills in a weekend when the
rare opportunity arose to do so without significant financial outlay, as
a result of his connections. The dramatic increase in use was directly related
to his coming into possession of a substantial quantity of MDMA powder.
He became highly tolerant, and reported that 250mg taken orally had almost
no effect. The highest quantity taken in 24 hours was 4 grams. The powder
was tested and was of a very high purity, with no adulterants. Despite severe
depression, he was unable to stop using MDMA although he believed that this
was a cause.
His father had schizophrenia and died when he was 12, and his mother
was 'very eccentric'. He was an only child, and a loner at school with a
strong anti-authoritarian stance. He attended University. For several years
in his mid-twenties he was employed as a technician, co-owned a flat with
a girlfriend, and went to clubs and parties. However, he was dismissed after
a disagreement with his employer, the flat was repossessed, he parted from
his girl-friend and he returned to live with his mother. There was a clear
history of general constriction of his world and increasing social isolation.
He had been unemployed and without a partner for several years when seen.
His few social contacts all arose out of his opiate and benzodiazepine dependence.
At that stage, almost all of his drug use, including the injection of MDMA,
was carried out when he was alone, in his room upstairs, apart from a few
drinks in bars. He had no known medical or psychiatric history and denied
that he had ever been arrested. He also used dexamphetamine in occasional
binges, cannabis, at least 50 units of alcohol per week (sometimes far more),
a range of benzodiazepines and a range of opioids. He had been heroin (or
equivalent such as dissolved morphine tablets) and benzodiazepine dependent
for at least 3 years. He smoked 20 cigarettes per day. His interpersonal
style displayed some disregard for normal social conventions but there was
no evidence of psychosis when seen. He denied any psychotic episodes linked
to the MDMA use but described brief yet severe paranoid episodes after occasional
injection of dexamphetamine.
Case C: A 25 year old male electrician (C) with post-traumatic stress
disorder (PTSD), characterised by feelings of emotional detachment, took
MDMA for the first time and suddenly felt connected with other people again.
His use rapidly escalated over several months, use levels being limited
by financial considerations. After 2 years he was taking 25 -30 tablets
every weekend. His mother confirmed all aspects of the history, and stated
that he had sold everything he owned so that he could buy MDMA, alcohol,
and 'go clubbing'. He sold his television, video and clothes. He would go
without sleep for days at a time, and would not eat. She said: 'He was a
completely changed person...he sold everything. He would walk out of here
with a £90 shirt on and would come home the next day with some-one's
old T-shirt on...' A tested tablet contained MDMA. He also had a very substantial
alcohol intake (one bottle of Jack Daniels whiskey almost every night) but
did not use other drugs apart from 20 cigarettes per day. He said that Ecstasy
prevented him from becoming drunk. He was uncertain as to whether he experienced
alcohol withdrawal symptoms which could be distinguished from the general
adverse effects of the night before. The use of alcohol was daily, but the
use of MDMA followed a similar pattern to case A, being largely limited
to Thursday night until the early hours of Monday morning. Like case A,
he also attended 'breakfast clubs' following nightclubs. Despite evidence
of harm to himself, his use of both MDMA and alcohol continued.
The PTSD followed his being a witness to a combined murder and suicide.
He felt guilty that he had not intervened as he believed that he could have
done so. After the incident he could not return to work or relate to his
girlfriend in a normal way. She left him as a result. He moved back to his
parents' house. He experienced flashbacks of the tragedy, nightmares, emotional
bluntening, a feeling of detachment from others, loss of the ability to
enjoy life, high anxiety, insomnia and suicidal ideas. After spending several
weeks in bed he began to drink large quantities of alcohol. One night he
was offered MDMA in a club. This was highly effective in removing the emotional
bluntening and social withdrawal. He denied a previous history of illicit
drug use. He said that the Ecstasy was a 'whole new world...suddenly everybody
cared'. He took increasingly large numbers of tablets: 'you take 2 or 3
every few hours, just do them like smarties..' He was arrested with 50 tablets
in his possession and charged with intent to supply on the basis of quantity,
but was found guilty of possession only.
His father was an unemployed tradesman who was formerly alcohol dependent
until admitted to hospital with medical complications. These facts were
confirmed by external medical sources. As a child, he saw a psychologist
because of poor temper control. He left school to become a father at 16.
He had two children and then separated from his partner who has custody
of the children. He worked as a labourer and subsequently became an electrician.
The partner who left him after the murder had been with him for several
years. There was no medical or psychiatric history other than that noted,
and he was was not prescribed any medication. He had no previous convictions.
He was always inclined to worry and had obsessional tendencies. When first
seen, he appeared anxious with sweaty palms, restlessness, and a pulse rate
of 105. He described being anxious and low in mood with initial insomnia,
early morning wakening, poor appetite with weight loss, low energy, and
anhedonia. He had stopped going out to nightclubs and had frequent suicidal
ideas. He expressed extreme guilt about not intervening to prevent the murder/suicide.
He was still experiencing nightmares and 'flashbacks' of the incident.
3. Discussion and Conclusions
A dependence syndrome requires at least 3 of: a strong desire to take
the drug; difficulties controlling the behaviour; a withdrawal state; tolerance;
progressive neglect of alternative pleasures and persisting with use despite
evidence of harm (World Health Organisation, 1992). These features occurred
in all 3 cases, who considered themselves harmed in various ways, made attempts
to stop but yielded to a compelling desire to re-use, and listed fatigue,
low mood, anxiety and sleep disturbance as withdrawal phenomena. One case
was also amphetamine dependent, one was also dependent on benzodiazepines
and opioids with a relatively high regular alcohol intake, and one also
had a high daily alcohol intake verging on dependence. The last case also
met diagnostic criteria for PTSD, a condition in which excessive use of
alcohol and other drugs is a recognised complication (World Health Organisation,
With repeated, high frequency use, the effects of MDMA may become gradually
less empathy- generating and more like amphetamine, although the parameters
of this phenomena are still largely anecdotal (Peroutka, 1990; Jansen, 1997).
Some users who reach this stage then lose interest in the drug, but as these
cases demonstrate, a few users may increase their dose levels, and rare
cases may proceed to develop amphetamine-like dependence. The reasons may
be that these users seek to regain the initial effects of the drug, that
they are attracted to the general stimulant effects which remain, and also
the social and psychological factors which increase the risk of dependence
with other drugs, such as self-medication of underlying disorders, unresolved
personal issues, ready access to the drug and a family history of high levels
of drug use (including alcohol). For those who are professionally involved
with clubs and dance events, such as promoters and DJ's, excessive use of
psychostimulants may be an occupational hazard.
Possible pharmacological factors are more controversial. Like amphetamine,
MDMA can release dopamine, activating pleasure centres in a manner 'consistent
with the action of drugs with dependence liability' (Nichols and Oberlender,
1989). Rhesus monkeys will sometimes engage in repeated self-injection of
MDMA (Beardsley et al., 1986; Lamb and Griffiths, 1987). High doses of MDMA
can reduce serotonergic function in animals (McCann et al., 1996, Ricuarte
et al., 1988), but serotonin reductions appear to increase, not decrease,
self administration of amphetamine-like compounds in some animal studies,
although MDMA was not included in these studies (Lyness et al., 1981). The
applicability of these animal studies to human situations is unclear, particularly
in view of the fact that the large majority of MDMA use is of a non-dependent
variety. Nevertheless, it appears that rare cases may develop MDMA dependence
with potentially serious consequences. Each of these 3 cases is in some
way exceptional relative to the population of persons who attend weekend
dance events, the major context for MDMA use. Identification and treatment
of this group, although small, must not be neglected as there may be some
risk of nerve terminal damage at these very high levels of use (Ricuarte
et al., 1988; McCann et al., 1996).
With respect to treatment, the general principles used to treat MDMA
related problems have been discussed elsewhere (Jansen, 1997). The alcohol
problem created additional complexity in case B, while in case C the problems
of addiction to opiates and benzodiazepines became central although it was
the MDMA use which had been the initial reason for this person making contact.
All 3 cases are currently abstinent from MDMA and amphetamines. The heroin
user is now injecting prescribed methadone ampoules from a private doctor
and uses benzodiazepines sporadically. The person with PTSD has a reduced
but still substantial alcohol intake. The nightclub promoter found a daytime
job and made substantial lifestyle changes. He continues with near daily
cannabis use but no other drugs apart from a moderate alcohol intake. All
continue to smoke 20 cigarettes per day.
The author is grateful to Dr. Michael Farrell and Dr. Tom Fahy of the
Maudsley Hospital for assistance with the manuscript, and to the Multidisciplinary
Association for Psychedelic Studies for the supply of a computer.
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