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     One of the more exaggerated aspects of Ecstasy (MDMA) use is the perceived rate of death and injury. The graph below shows the number of Emergency Room visits associated with various drugs in 2001. (Data was collected and provided by the US Substance Abuse and Mental Health Services Administration.) This was the highest year so far for 'ecstasy' related ER admissions.




     Although the number of ER visits associated with 'ecstasy' is relatively low, the thought of over five thousand users near death's door being hauled in by ambulances is rather troubling. But...the data doesn't mean what it seems to imply at first glance. Look at the "marijuana" column near the bottom. For every case where 'ecstasy' was present, there were about twenty marijuana-related cases. How can this be? Marijuana is extremely safe; the vast majority of these people were clearly not in medical danger. The explanation is that people on psychoactive drugs often come to the ER because they think something might be wrong; they get scared. With MDMA, a lot of 'got scared' stories appear to be happening as well. A study of ER admissions in the Netherlands found that, of the patients there for some complaint related to 'ecstasy', most (89%) did not require treatment beyond the initial visit/talk with a doctor.[1] Most ER cases also involve alcohol. [2] (If you feel something might be wrong, either with yourself or somebody else, do not hesitate to seek medical attention. Maybe it's nothing serious, but better to be safe than sorry.)

     From this data, the total rate of ER visits among 'ecstasy' users is approximately 1 in 600 users per year. If we assume that the experience of the Netherlands is comparable to that of the US, we might assume a rate of actual emergency medical problems associated with 'ecstasy' use of approximately 1 in 6,000 users per year. Numbers alone don't really tell the whole story, however: Where things get interesting is not how many users encounter medical problems, but why they do. The distribution of injuries and deaths is not random throughout the user population; it is associated with specific risk factors and behaviors. (Read the rest of the Risks section for more information.)


     The number of ER visits rapidly increased from 1994-2001, declining in 2002 (apparently due to reduced rates of use.) Most of this increase was simply due to the greatly increased number of people using 'ecstasy'. However, the ER visits increased at a faster rate than use, leading me to speculate that users are becoming more likely to seek medical attention if they fear something is wrong, coupled with increases in use by younger and less competent/careful users.



     Most of the people that show up in the ER, even those in genuine medical danger, will make a full recovery. Most...but not all. In recent years in the US, the greatly increasing rate of MDMA use has made deaths a somewhat regular occurrence. Listening to the government 'drug experts' you might think users were dropping like flies. The truth, as usual, is less grim than the drug warriors would have us believe:

Deaths involving MDMA (from districts reporting to SAMHSA):

Reported Deaths:

*Incomplete data; the actual total is probably closer to 100.

Graphically represented, the data spike of 1998-2000 is even more obvious. This increase is something of a mystery, given that the overall rate of use seems to have only about doubled between 1996 (8 deaths) and 2000 (63 deaths.) The increase in reports does, however, better match the increases in Emergency Room visits. My concern is that this trend was partly the result of MDMA's spread from users who generally knew what they were doing to younger and more ignorant users. The government failed in both respects; They were unable to stop the growth of usage, and they refused to provide useful drug education to young people.

     Some important things need to be said about how this information is gathered. First, not all medical examiners (coroners) report to SAMHSA, particularly in rural areas. As a result, there have no doubt been some cases that have gone unreported. Also, the basis of reporting a death as "associated with MDMA" is not that it was caused by MDMA; rather that it was caused by drug use, and one of the drugs present was MDMA. This is a slippery distinction. For instance, if a person takes MDMA and drinks at a party, then, hours later, drives drunk and is killed in an accident, the death would be reported as MDMA-related. It's also possible that the increased number of 1999-2001 death reports is simply the result of more comprehensive toxicology screening finding MDMA in more people who died as a result of other drug use (such as alcohol or amphetamines.) The 2001 data came with more information: A listing of all the drugs involved in each case:

     As expected, amphetamine and methamphetamine made a showing. Somewhat surprising to me were the high numbers of cases involving cocaine and opiates (heroin, oxycodone, ect.) Out of a total of 76 deaths involving MDMA reported in 2001, only 9 involved only MDMA. It seems unlikely that cannabis was a significant factor in deaths.

    In a recent study in the UK, of 81 deaths where MDMA was present, only 6 died from simple MDMA toxicity.


     The leading causes of actual MDMA-related death are complications of "malignant hyperthermia/hyperpyrexia"...what most people would call Heatstroke. Perhaps the second most common cause of death (significantly less common than heatstroke-related) is Hyponatremia, sometimes called "water intoxication." Even rarer causes of death are due to underlying health problems (heart disease, etc.) being aggravated by MDMA's stimulant effects and a few 'misadventure' deaths (falls, etc.) Fatal cardiac arythmias have been claimed, but seem to be unreported in the case studies.


Putting things in perspective:

    The death rate for MDMA, assuming that there really were about 60 deaths directly caused by MDMA in 2000, would be roughly 2 in 100,000 users. The death rate from smoking, by contrast, is on the order of 400 per 100,000 users. Even alcohol, America's official "it's not really a drug" drug, nets about 50 deaths per 100,000 users each year:[3]


      Equally important in considering risks is that, while there is no safe way to be a pack-a-day cigarette smoker, most of the people that died as a result of their MDMA use did something unwise to cause their demise. An informed MDMA user is unlikely to be a hyponatremia death. No responsible MDMA user is likely to be a 'driving under the influence' or drug mixing death.

    Some people have objected to this comparison, saying that one beer or one cigarette is not as dangerous as one pill of MDMA. While that's true, my interest is (quite justifiably, I think) the overall risk posed by the lifestyle, not by per-unit risks. Yes, smoking a single cigarette is probably safer than taking one ecstasy tablet, but that's not the way real world users behave. The smokers don't stop at just one cigarette and the drinkers don't stop at just one beer. The statistics shown here mean exactly what they say: Your odds as an MDMA user of being killed from your MDMA use are a very small fraction of your odds as a smoker or drinker of being killed as a result of your smoking or drinking.


Rates of Use of MDMA ('Ecstasy')

     When it was first scheduled, MDMA was something of niche drug. Tens of thousands had probably tried it, but it hadn't made a big splash on the national drug scene. After scheduling, MDMA began an almost geometric pattern of growth. Today, on the order of 10-12 million Americans have used MDMA at least once in their life. If nothing else, the runaway growth of ecstasy use has demonstrated the almost complete inability of law enforcement to actually prevent drug use by fighting the supply side; where there is a demand, the supply will always find it.

     The group we have the most data on is young people (mainly high school students), thanks to the government funded Monitoring the Future survey, which studies eighth, tenth, and twelfth grade students (approximately ages 14, 16 and 18) from across the US.


    As shown in this graph from the MTF survey, use of MDMA by teenagers saw extremely strong growth in the late 90's, with use by high school seniors more than doubling just from 1998 to 2000.

    2002 to 2004 saw large declines in reported last-month usage. The 2002 drop is consistent with declines in MDMA-involved emergency room visits for 2002.  The curve appears to be bottoming out, however; it is likely that usage is approaching a minimum and will stabilize or even rebound.


     Perceived availability has a correlation with usage rates, although this is likely to be largely a trailing indicator (increasing usage causing increases in perceived availability.)


     The trend had been for slowly increasing acceptance of 'ecstasy' use by teenagers until 2002. There is a modest but significant correlation between Disapproval and usage levels.


     Fear-mongering anti-ecstasy ad campaigns appear to have paid off. In 2003 a new standard was set when the percentage of high school seniors who thought trying ecstasy would be very dangerous exceeded the percentage who though trying crack or methamphetamine would be very dangerous. Although perceived risk slightly increased in 2004, the curve is clearly flattening; anti-MDMA propaganda seems to be reaching the limits of its effectiveness.  Given the rather thorough discrediting of "it'll eat holes in your brain" propaganda, even these gains may well be temporary.   (See: Neurotoxicity.)


     Other data from MTF:

     • In 2001 at the 12th grade level, Hispanic students were slightly more likely than white students (13.1% vs. 12.4%) to have tried MDMA, while only a small number of black students (3.1%) had tried the drug. (Perhaps surprisingly, rates of drug use by black teenagers are much lower than for whites in almost all categories, including crack cocaine. Why then are our prisons crammed with black drug offenders?)

     • Among college-aged people (1-4 years past high school) the lifetime prevalence of MDMA use was approximately 16% (people attending college were somewhat less likely to have tried it.)

     • Males are somewhat more likely to have used MDMA than females.

     • Distribution of use is fairly even among all regions of the US (except for the south which had significantly less use) and all parental educational backgrounds (children of the least educated parents were less likely to have used.)

     • Major cities had ~60% more past-year use than small towns.


[1] Spruit IP "Ecstasy use and policy responses in the Netherlands" Journal of Drug Issues, 1999; 29(3):653-678. Abstract

[2] Substance Abuse and Mental Health Services Administration/DAWN Emergency Department data.

[3] Death numbers are based on 'rough justice': The US Centers for Disease Control reports over 100,000 alcohol related deaths per year, with close to 200 million Americans using alcohol. CDC also reports over 400,000 smoking related deaths per year out of about 100 million smokers. The 'ecstasy related' drug deaths number is based on an assumption of about 60 deaths (in all probability there were only a handfull of purely 'ecstasy' deaths) out of a user population of about 3 million (based on the 2000 National Household Survey on Drug Abuse Statistics, conducted by SAMHSA.)