Medical Editor: Dr. Lynn Marie Morski, MD, Esq
MDMA has garnered the attention of people from many different backgrounds and walks of life, either due to its appeal as a potential catalyst in the psychotherapeutic process, as an interesting idea for recreational exploration, or as a source of concern amidst reports of its abuse.
Understanding MDMA and its effects will help clarify uncertainties about the potential benefits and risks. Here are the need-to-know basics.
What is MDMA?
4-Methylenedioxy-methamphetamine (MDMA) is a synthetic, psychoactive substance best known for producing a euphoric state with simultaneous stimulant and psychedelic effects.
In 1912, it was created by German chemists attempting to remedy blood loss. It was patented by the drug company Merck shortly thereafter and was briefly used by the CIA to explore psychedelics as a means for mind control in Project MK-Ultra during the Cold War.
Friederike Meckel Fisher and other practitioners of psychedelic-assisted psychotherapy advocated for MDMA’s use as a tool in both individual sessions and couples counseling, saying it “alleviates fear” and enables people to “access parts of their minds they might normally suppress.”
The Nixon administration enacted the Controlled Substances Act in 1970, declaring a ‘War on Drugs.’ MDMA was listed as a Schedule 1 drug and became banned in 1985 after it had become popular among recreational users.
The change in legal status did little to alter the popularity of MDMA as the main ingredient of drugs used in social settings such as electronic dance music (EDM) or ‘rave’ events, though when produced outside of clinical settings it is often found to be contaminated with a variety of other substances. In recreational use, MDMA is also commonly referred to as ecstasy, molly, or E.
It continues to be the subject of research, with growing evidence for the benefits of MDMA-assisted therapy in treating post-traumatic stress disorder (PTSD) and social anxiety in adults with autism. The U.S. Food and Drug Administration (FDA) recently awarded Breakthrough Therapy designation to MDMA-assisted psychotherapy for PTSD, which expedites the processing of study findings and allows the potential for a quicker path to approval for therapeutic use.
How MDMA works
The effects of MDMA are produced by increasing levels of hormones and the neurotransmitters serotonin (5-HT), dopamine (DA), and norepinephrine (NE). Serotonin is partially responsible for mood regulation. MDMA triggers the release of serotonin and simultaneously blocks its reuptake temporarily, allowing for buildup in the brain. Dopamine affects the reward processing function of the brain, making interactions feel more meaningful and boosting energy. Increased norepinephrine levels cause elevated blood pressure and heart rate.
Methods of intake
MDMA is most commonly ingested orally in the form of a tablet, gel capsule, or loose powder and crystals. Crushed into a fine powder, MDMA is sometimes snorted and absorbed by the small blood vessels inside the nose by way of the mucus membrane.
As of now, information is lacking on the prevalence, effects, and risks of smoking or injecting MDMA, as these methods are far less common.
Is MDMA the same as molly or ecstasy?
MDMA is the scientific term, but recreational users often refer to MDMA as molly or ecstasy. Assumption of its purity is common; however, MDMA that hasn’t been formulated by research scientists is commonly adulterated with other substances in recreational forms of the drug. Street drugs that claim to be MDMA may have little to no MDMA content.
MDMA Effects and Benefits
The characteristic positive effect of MDMA is euphoria. Depending on one’s mindset, companions, and environment, it can manifest in a variety of ways. Feelings of connectedness to the inner self and other people, a heightened sense of spirituality, being more social or open to new ideas and experiences, increased arousal and awareness of physical sensations, meaningful interaction with art and music, mild visual and auditory hallucinations, and feeling generally at peace are a few examples.
While these effects make MDMA a popular recreational enhancement for creative and social events, as evidenced by the research cited above, many have reported transformative, intimate experiences through taking the drug in more formal, therapeutic settings.
How long does MDMA last?
Depending on several factors, the effects of MDMA can last anywhere from 3 to 6 hours after a single dose of unadulterated MDMA. Re-dosing might extend the length of efficacy for a certain amount of time depending on tolerance and medications, other substances, or health considerations.
A study of urine samples taken from a group of participants given a single oral dose of MDMA showed that most of the substance was excreted through urine within the first 24 hours after application. Depending on the individual, dosage, testing method, and scope, MDMA has been detected in trial participants within the first hour of oral intake and up to 7 days later.
Research and current uses
In the 1960s and ’70s, MDMA became a tool for lowering the inhibitions people often feel when reflecting on painful and traumatic experiences, allegedly resulting in more productive therapy sessions according to the few therapists who utilized it.
Although it was banned as a recreational drug in 1985, MDMA has shown promise in clinical studies of the benefits demonstrated when treating severe post-traumatic stress disorder (PTSD) for cases where conventional methods alone have been insufficient. It was approved for Breakthrough Therapy designation by the U.S. Food and Drug Administration (FDA) in 2017, which allows for expedited development and review of a substance that shows promise in treating serious conditions.
Such a designation also requires proposed drugs to demonstrate the likelihood for “substantial improvement over available therapies” in existing studies. It is now in phase 3 trials for the treatment of PTSD, with a specific protocol for MDMA-assisted therapy studies sponsored and outlined by The Multidisciplinary Association for Psychedelic Studies (MAPS).
Research has also focused on MDMA as a possible treatment for severe social anxiety in adults with autism when conventional approaches failed to improve symptoms. There was encouraging, conclusive data showing improvements in the LSAS (Leibowitz Social Anxiety Scale) score for the group administered MDMA, described in the study results as ‘significantly greater’ than the recipients of placebo.
Very recently, researchers have begun to explore whether or not MDMA-assisted psychotherapy could possibly be effective in the treatment of eating disorders and anxiety in adults coping with a life-threatening illness.
People in relationships have also leveraged the feelings of connectedness facilitated by MDMA in the context of therapy, particularly when one or both suffer from PTSD or the effects of trauma that can impact the dynamic of a partnership.
The impact of MDMA in the treatment of PTSD is dependent on its use in conjunction with psychotherapy. MDMA appears to help dismantle some of the emotional defense mechanisms that hinder survivors of trauma from benefiting in a psychotherapeutic session, such as a tendency to withdraw or become overwhelmed and upset when the therapeutic session becomes challenging. Research also suggests that it might minimize reactions of distress in discussions that would otherwise trigger a negative emotional response.
Research speculates that MDMA can facilitate trust with a therapist that is otherwise established over years of difficult effort, if at all. This is likely due to the fact that in addition to promoting the release of several monoamine transmitters (primarily serotonin or 5-HT) and temporarily preventing their reuptake, it increases levels of serum oxytocin. This neuropeptide is thought to be partially responsible for bonding in mammals. As Anne Wagner (Adjunct Professor of Psychology at Ryerson University) describes it, MDMA-assisted psychotherapy offers the hope “to move the seemingly immovable presence of the trauma.”
MDMA side effects and risks
Side effects of MDMA are common and range from mild to severe.
Clenching teeth, elevated body temperature with the risk of hyperthermia, dry mouth, sweating, hyponatremia, nausea, diarrhea, muscle cramps, blurry vision, reduced appetite, tremors, and chills are some of the possible adverse physical effects. When heart rate and blood pressure increase after the administration of MDMA, there is the risk of serious complications for those with existing heart disease and other health issues. MDMA also has the potential to interact poorly with prescription medications or in combination with different substances.
The acute psychological side effects most often reported are anxiety and paranoia, sometimes with visual or auditory hallucinations. Despite possible short-term relief from symptoms, the abuse of MDMA can ultimately worsen depression, mood, and personality disorders by causing a deeper imbalance of chemicals in the brain and should be avoided by anyone with such diagnoses.
Cases of fatal overdose from MDMA alone are rare considering its underground popularity, but polydrug use and the related deaths are not accounted for in data examining exclusive usage of MDMA.
In the days following the use of MDMA, symptoms like depression and fatigue are likely due to depleted levels of serotonin and exhaustion following recreational use on weekends.
Increasingly frequent use of MDMA can lead to the development of tolerance and therefore dependency, requiring increased dosage to experience the effects.
Is MDMA safe?
Psychoactive substances like MDMA have both psychological and physical effects that can be unsafe for a variety of reasons, such as causing or worsening certain physical and mental health conditions.
A study with acute administration demonstrated that MDMA appears to be safe for healthy adults with benefits outweighing adverse effects, but also noted the risks for those with health concerns or diagnosis of cardiovascular and psychiatric disorders.
Outside of a professional therapeutic setting, there is significant concern about substance purity. Tablets, crystals, and powders sold illegally and called molly or ecstasy have been found to be up to 90 percent impure, containing 18 different substances across 1,232 samples in a probe of substances seized by police. Contaminants like synthetic stimulants and new psychoactive substances are undetectable without testing.
While test kits are commercially available, an analysis of the accuracy in reagent test kit results revealed a lack of test accuracy. More accurate and accessible testing methods are required in order to effectively facilitate harm reduction.
Hair samples of users who self-reported use of MDMA, molly, or ecstasy within a year of the study revealed that 51.1 percent of participants tested positive for substances they didn’t report. 72 percent tested positive for synthetic cathinones, which are stimulant drugs known more commonly as ‘bath salts.’ Methamphetamine and speed (amphetamine) were found in 49.2 percent of samples containing a substance other than MDMA in a survey of participants who used a test kit to determine the purity of a substance they intended to take.
Reliable information about MDMA is available from these sources:
Multidisciplinary Association for Psychedelic Studies (MAPS)
Scientific Literature, Government Hearings, and Archive
U.S. National Library of Medicine – Methylenedioxymethamphetamine (MDMA) in Psychiatry: Pros, Cons, and Suggestions
Global Drug Survey harm reduction checklist for first-time users of MDMA
Drug Policy Alliance MDMA Fact Sheet