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N-methamphetamine (MDMA), otherwise known as “ecstasy” is a “psychedelic amphetamine” that has gained popularity the past twenty years because of the feelings of comfort, empathy, and connection to others it provides for the user. MDMA is considered an illicit substance in the United States, as it is in most other countries. MDMA was first synthesized in the 1890s, and it wasn’t until the 1970s and ‘80s that it was used as a psychotherapeutic tool and also started to become available on the street.

Its growing popularity resulted in it being made illegal in the United States in 1985; since then the drug’s popularity has continued to increase. The issue of MDMA’s neurotoxicity is very complex, including debate about what constitutes neurotoxicity, but almost all experts now agree that MDMA is a neurotoxin. Keywords: MDMA, Ecstasy, XTC, neurotoxin, illegal, amphetamine, psychedelic MDMA most frequently comes in tablet form, although it is also found in capsules or as a powder. It is most commonly used orally and rarely snorted.

MDMA use is usually associated with the rave scene throughout the world, but was also used by therapists in experimental psychotherapy. Ecstasy’s demand usually exceeds supply, which creates the opening for certain individuals to sell virtually anything as “ecstasy”. This is why ecstasy pills are notoriously unreliable in content, more so than most other street drugs. The most common substitutes for MDMA are caffeine, ephedrine, amphetamines, MDA, MDE and DXM. (Julie Holland, 2001) A standard oral dose of MDMA is between 80 – 150 mg.

Most good quality pills contain somewhere in this range, generally 80 – 120 mg. A large percentage of users find that there is a “sweet spot” in MDMA dosage. Once this spot is found, higher dosages are not particularly desirable as they do not increase the sought after effects or duration. (Julie Holland, 2001) MDMA is criminalized in most countries in the world under a United Nations agreement, and its possession, manufacture or sale may result in criminal prosecution, not including exceptions made for scientific and medical research.

After the illegalization of MDMA, drugs such as 2CB were synthesized as a way around the legislation. Drugs such as this were chemically similar, and produced similar effects. In some countries, such as Germany, this works as a loophole to delay the illegalization of a drug and its variants. Although in the US, any new drug which has been designed to avoid the law is automatically prohibited. (World Drug Report, 2008) There has been much debate about the risk of MDMA, specifically the possibility of neurotoxic damage to the central nervous system.

The Multidisciplinary Association for Psychedelic Studies released the following statement in October 2008, “We found the low doses of MDMA (between 50 and 75 mg) were both psychologically and physiologically safe for all the subjects. Future studies in large samples and using larger doses are needed in order to further clarify the safety and efficacy of MDMA in the clinical setting in subjects with PTSD. ” (Ruse, Jerome, Mithoefer, Doblin, & Gibson, 2008). Like any drug, MDMA produces a plethora of effects, both positive and negative.

Among the positive effects are a mild to extreme mood lift, also known as euphoria, increased willingness to communicate, increase in energy, decreased fear and anxiety, feelings of love and empathy, forgiveness of self and others, increased awareness and appreciation of music, and an increased pleasure from the sense of touch. (Stillman R. , 1978) Neutral effects include appetite loss, visual distortion, nystagmus, mild visual hallucinations (uncommon), moderately increased heart rate and blood pressure, restlessness, and change in body temperature regulation. (Stillman R. 1978)

Negative side effects are inappropriate and/or unintended emotional bonding, anxiety, paranoia, agitation, tendency to say things you might feel uncomfortable about later, mild to extreme jaw clenching, tongue and cheek chewing, teeth grinding, difficulty concentrating, problems with activities requiring linear focus, short term memory loss, muscle tension, insomnia, erectile dysfunction, hyponatremia, nausea, headaches, and vertigo. These are effects that are very rarely experienced with low to moderate use, but can been seen with higher doses and frequent use. (Stillman R. 1978)

The above listed effects are uncommon, but possible negative effects experienced while on the drug. The “comedown” or “hangover” experienced the days after MDMA usage are far more common and are usually experienced after each usage. Although, like the negative effects, at higher doses and frequent use the hangover effects become increasingly worse. The most common after-effect is mild depression and/or fatigue lasting up to a week. A more uncommon effect, although reported, is a severe depression and/or fatigue. Ecstasy, like many other drugs, can be very harmful if abused.

Studies have shown a positive correlation between long time chronic users and depression. An article by Professor David Nutt published in the Journal of Psychopharmacology shed light on the lack of a balanced risk assessment in public discussions of MDMA(D. Nutt, 2009): “The general public, especially the younger generation, are disillusioned with the lack of balanced political debate about drugs. This lack of rational debate can undermine the trust in government in relation to drug misuse and thereby undermining the government’s message in public information campaigns.

The media in general seem to have an interest in scare stories about illicit drugs, though there are some exceptions (Horizon, 2008). A telling review of 10-year media reporting of drug deaths in Scotland illustrates the distorted media perspective very well (Forsyth, 2001). During this decade, the likelihood of a newspaper reporting a death from paracetamol was 1 per 250 deaths, for diazepam it was 1 in 50, whereas for amphetamine it was 1 in 3 and for ecstasy every associated death was reported. ”

A British study, taking account of the number of users, estimated that 0. per 10000 users of ecstasy result in death (Gore, 1999). Many theorize that the current way society deals with drugs could have a negative effect on the amount of deaths caused by ecstasy. Most anti-drug campaigns explain reasons why you should not do the drug, but very little information is available about what to do to stay safe while on the drug.


Part 1: Mr. YY, your 75 year old male patient presents to a routine check-up with concerns about his memory. He has been aware of a declining short-term memory (not being able to recall names of people, movies or recent events). Mr. YY is under a lot of stress as his wife was recently diagnosed with dementia and he is her primary caregiver. Mr. YY has hypertension, dyslipidemia, T2DM, and insomnia. His current medications include: lisinopril 40 mg daily, atorvastatin 20 mg daily, metformin 500 mg bid, and zolpidem 5 mg nightly. This week your first post is to differentiate between normal memory loss, dementia, Alzheimer’s and delirium including screening tests plus include one of the following in your discussion: 1. Explore other etiologies of cognitive changes that might be present in the older population, Mr. YY such as psychosocial, pharmacological and other system decline. 2. What are the implications of cognitive decline in the older patient for a clinician in care management? Part 2: Mr. YY had changes in medical care plan and is doing well for a short while. His last visit, he was near baseline. Today you observe on his visit that he is less engaged and hygiene is lacking. Mr. YY is not leaving his house to events that he used to like to attend. He also had a fall last week and only tells you when you notice all of the abrasions on his arm. Based on his presentation, what might you be concerned about? You suspect that he is depressed and having care-giver stress along with being isolated. 1. What would be your next steps? 2.What are the ethical considerations/care planning needed? Part 3: After several months, you are concerned that Mr. YY is not taking care of himself so how can he be taking care of his wife, who is also your patient? You ask him to bring her in for a check-up. Mrs. YY is a bit older than her husband at 79. On Mrs. YY’s check-up you note she is frail, disheveled, and has bruises over her lower extremities and arms. Mrs. YY assures you she is fine and adamantly wants to stay home. She tells you that you would have to “shoot her first” before she went to any retirement home. Mr. YY recently let go of a home-health aid he hired as she was “just sitting there staring at us.” Her medical problems include arthritis, hypertension, and allergic rhinitis. Current meds include: ASA 81 mg daily, lisinopril 20 mg daily, and diphenhydramine 50 mg each bedtime. 1. Identify any red flags in this scenario regarding complexity of medical care and psychosocial issues. 2. What might be your next actions? Ethical concerns? 3. Name some communication strategies you might employ with Mr. and Mrs. YY to discuss advance care planning and coordinating a home safety plan?

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