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Treatment implications for young adult users of MDMA.

Young adults' 3,4-methylenedyoxymethamphetamine (MDMA) use is a national public health concern. Although research on the epidemiology of MDMA use has increased, inquiry into intervention and treatment is needed. The authors examine results from an epidemiological investigation from a clinical perspective and provide suggestions for clinicians working with MDMA users.

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Research shows that 3,4-methylenedyoxymethamphetamine (MDMA), commonly known as ecstasy, is currently one of the more popular recreational drugs in the Western world (Corapcioglu & Ogel, 2004; Martins, Mazzotti, & Chilcoat, 2005). A synthetic analog to amphetamine with hallucinogenic features similar to those of mescaline, MDMA is often described as an entactogen (defined as to produce a touching within) for its ability to heighten but not distort sensory perceptions (Gahlinger, 2004). Merck Pharmaceuticals developed MDMA in 1914 as an appetite suppressant. However, results from initial animal drug testing were inconclusive, and MDMA originally was not tested on humans (Connor, 2004). In the 1960s and 1970s, MDMA was used to heighten sensory experience, both recreationally and psychotherapeutically. In 1965, psychiatrists began prescribing MDMA to enhance introspective states, communication, and intimacy (Martinez-Price, Krebs-Thomson, & Geyer, 2002). However, in response to subsequent reports of neurotoxicity in 1985, the Food and Drug Administration classified MDMA as a Schedule 1 controlled substance (i.e., no approved medical use, high abuse potential, and lack of accepted safety for use in medical purposes), and its use was made illegal (Freese, Miotto, & Reback, 2002).

MDMA has complex neuropharmacological effects through stimulating acute release of serotonin (Croft, Klugman, Baldeweg, & Gruzelier, 2001; Maartje et al., 2004), dopamine (Colado, O'Shea, & Green, 2004), noradrenaline (Back-Madruga et al., 2003), acetylcholine (Montoya, Sorrentino, Lukas, & Price, 2002), and histamine (Martinez-Price et al., 2002). Typical effects of MDMA use include a relaxed, euphoric state; teeth grinding (bruxism); jaw rigidity (trismus); emotional openness; increased empathy, extroversion, and physical energy; and a decrease in inhibitions (Pape & Rossow, 2004). Acute neuropsychiatric effects include moderate derealization, depersonalization, thought blocking, impaired decision making, and slight elevation in anxiety (Schifano, 2000). The physiological influences of MDMA use include hyperthermia, increased heart rate, and elevated blood pressure (Croft et al., 2001).

At higher or repeated doses, MDMA has been found to be neurotoxic to serotonin systems in the brain of primate and other animal species, resulting in a user's vulnerability to depression (Dafters, Hoshi, & Talbot, 2004; McGregor et al., 2003), anxiety (Dughiero, Schifano, & Forza, 2001; Parrott et al., 2002), impulsivity (Curran, Rees, Hoare, & Bond, 2004; Moeller et al., 2002; Morgan, 1998), and other mood impairment (Maartje et al., 2004; McCardle, Luebbers, Carter, Croft, & Stough, 2004). Chronic MDMA users report short-term and long-term memory deficits (McCardle et al., 2004) and greater risk of immunosuppression (Connor, 2004) and Parkinson's disease (Kuniyoshi & Jankovic, 2003). Research also suggests that physical and psychological morbidity (e.g., depression, anxiety, and heightened mood swings) from this drug are increasing, especially among adolescents and young adults (Broening, Morford, Inma-Wood, Fukumura, & Vorhees, 2001; Rowe, Liddle, Greenbaum, & Henderson, 2004).

The 2002 National Survey on Drug Use and Health (Substance Abuse and Mental Health Services Administration [SAMSHA], 2003) found reported lifetime use of MDMA among individuals between the ages of 18 and 25 years to be 15.1%, past year use to be 5.8%, and last month use to be 1.1%. Furthermore, individuals 18 to 25 years old composed nearly two thirds of all ecstasy users (SAMSHA, 2003). Similar results among individuals between the ages of 14 and 25 years were found in the 2002 National Institute on Drug Abuse's (NIDA; 2003) Monitoring the Future survey (13.5% lifetime, 5.6% past year, and 1.2% past month). High percentages of MDMA use among undergraduate students were found in several university-specific surveys (McCabe, Boyd, Hughes, & d'Arcy, 2003; Waiters, Foy, & Castro, 2002). In a sample of 1,264 undergraduate students at a private, southern university, Cuomo and Dyment (1994) found that 24.0% of participants reported having used ecstasy in the previous 4 years. These results indicate a high prevalence of MDMA use among young adults, thereby highlighting the need for further examination of this at-risk age group.

Although research on the epidemiology of MDMA use among young adults is increasing (NIDA, 2003; Yacoubian, Boyle, Harding, & Loftus, 2003), there continues to be scant inquiry into intervention and treatment. Confounding issues that have hindered these efforts to study MDMA have included prevalence of alcohol and illicit drug use, especially cannabis (Daumann et al., 2004); infrequent identification of MDMA as a primary drug of choice by both the user and the researcher (Boeri, Sterk, & Elifson, 2004; Jansen, 1999); and perceived low risk associated with MDMA use (Falk, Carlson, Wang, & Siegal, 2004). Nevertheless, the potential side effects of MDMA are particularly deleterious to adolescent and young adult users because of cerebral and hormonal vulnerabilities during the maturation process (Maartje et al., 2004; Schifano, 2000). In particular, early depletion of serotonin may perturb the developmental processes of the cerebral cortex, thereby interfering with lifelong modulation of affect (Montoya et al., 2002). These concerns make it especially important for all helping professionals to understand the unique risks and usage patterns of MDMA and the intervention strategies for working with young adult MDMA users.

In this article, we examine data from an epidemiological survey project from an assessment perspective and provide suggestions for mental health professionals working with MDMA users. The primary research questions and associated hypotheses addressed in this article include the following:

Research Question 1: What is the relationship between alcohol and illicit substance use, on the one hand, and differing diagnostic criteria of young adult MDMA users, on the other?

* Gay, lesbian, and bisexual young adult users of MDMA are more likely to be dependent users of MDMA than are heterosexual young adult users of MDMA.

* Young adult male users are more likely to be dependent MDMA users than are young adult female users.

* Dependent users of MDMA will report higher levels of marijuana, methamphetamine, and cocaine use than will recreational or abusing users of MDMA.

Research Question 2: Does the perception of risk associated with MDMA use differ by a user's diagnostic classification?

* Dependent MDMA users are more likely to report greater risks associated with the drug's use than are recreational or abusing users.

Research Question 3: Are dependent users of MDMA more likely to view chemical dependency treatment more negatively than are recreational or abusing MDMA users?

* Dependent users of MDMA are more likely than are recreational and abusing MDMA users to believe substance abuse treatment is too demanding.

* Dependent users of MDMA are more likely than are recreational and abusing MDMA users to view chemical dependency treatment as not working.

Method

Study Procedure

We used community identification methods to develop targeted sampling strategies in a population of young adult ecstasy users in a major metropolitan area in the Southeast (Tashima, Cram, O'Reilly, & Sterk-Elifson, 1996). We identified epidemiological indicators of prevalence and at-risk groups via emergency room admissions, law enforcement statistics, and expert opinions from local public health and political leaders. Persons eligible for the study had to meet the following criteria: They had to (a) have used MDMA on at least four separate occasions in the past 90 days; (b) not currently be in substance abuse treatment; (c) have no acute cognitive impairment by drug or alcohol use at time of interview, including no alcohol or drug use within the past 24 hours (no confirmatory drug analyses were conducted); and (d) be between the ages of 18 and 25 years.

All interviewers were screened and selected by Brian I. Dew (first author). The interviewers were all graduate-level students in sociology, public health, and psychology. Prior to the collection of any data, all interviewers were trained by Brian J. Dew regarding ethical guidelines, participant safety, qualitative research strategies, interviewing data collection, confidentiality, informed consent, and logistical concerns.

We used ethnographic recruitment techniques to access multiple communities and social settings. This approach allowed the field team to introduce the study to a variety of MDMA users in geographic areas with higher concentrations of young adults. Outreach staff recruited potential respondents in two primary ways. The first method consisted of direct communication with potential participants in the setting where they were recruited, such as raves, clubs, parks, areas near college dorms, and off-campus student housing. The candidate was informed of the purpose of the study and assessed for potential interest. If the individual was interested, the staff member gave him or her a short form to screen for eligibility. Nearly 6 out of 10 participants (n = 162) were obtained via this method. The second outreach technique involved passive recruitment, whereby flyers containing information about the study and a telephone number to contact were posted in venues that were highly populated by young adults (e.g., colleges and universities, coffee shops, nightclubs, and other social establishments). Potential respondents who called the project phone line were screened for eligibility and reminded of the voluntary nature of the research. If a respondent met the criteria and was interested in participating, we established a mutually agreed on date and time. This second method of outreach resulted in nearly 40.0% (n = 106) of the total participants.

Individual, face-to-face interviews were held at such venues as the participant's home, a local restaurant, a coffee shop, a community center, or the interviewer's car. An additional review of the screening criteria was performed prior to the commencement of the interview. Approved consent forms were signed prior to data collection. Average length of time to complete the structured questionnaire was 2 hours (range = 1 to 3.5 hours). A stipend of $25 was paid to the participant when all the study protocols had been completed.

Study Sample

The sample in the present analysis consisted of 268 actively using young adult MDMA users (age: M = 20.82 years, SD = 2.36; range = 18 to 25 years). Sixty-nine percent were male, 51.0% self-identified as White, and 82.0% self-identified as heterosexual. More than 90.0% of the sample had used MDMA more than the minimum 4 times in the past 90 days (M = 14.29 days, SD = 13.13, range = 4 to 90 days). Route of administration used in the past 90 days was oral (n = 268; 100.0%), followed by intranasal (i.e., snorting; n = 77; 28.7%), smoke inhalation (n = 16; 6.0%), and injection (n = 3; 1.1%). In response to the question, "How many times in your life have you used ecstasy?" half (n = 134) of the participants self-reported lifetime MDMA use of more than 100 pills, whereas 34.0% (n = 94) reported a lifetime total of fewer than 50 pills. Twenty-two percent (n = 58) of respondents identified MDMA as their current drug of choice, compared with 55.0% (n = 138) who chose marijuana as a preferred drug.

Measures

We obtained formative results from a pilot study with a similar MDMA-using population assessed specifically for this study. All of the obtained data were based on self-reports. We used a structured survey based on the following validated instruments: (a) Depressive Experiences Scale (Blatt, D'Afflitti, & Quinlan, 1976), (b) Locus of Control Scale (Levenson, 1981), (c) Soda] Avoidance and Distress Scale (Watson & Friend, 1969), and (d) Revised Shyness Scale (Cheek & Buss, 1981). Our survey also included a variety of sociodemographic measures, including age, racial background, educational achievement, high school completion, current socioeconomic status, current employment status, homelessness, sexual orientation, and relationship status. We extensively evaluated participants' past and current use of MDMA. We assessed the respondent's first use of MDMA by age, route of administration (i.e., inject, smoke, snort, or swallow), amount taken, and perceived potential side effects. We also obtained information on frequency, amount of use, route of administration, and money spent on MDMA in the past 90 days. With regard to a participant's history of MDMA use (i.e., frequency, amount, route of administration, and money spent), all interviewers used open-ended questions to obtain information. Additional questions regarding MDMA use included dichotomous (yes/no) choices related to environment (e.g., "Have you ever taken ecstasy at your own place with no party going on?" "Have you ever taken ecstasy at a party, club, or rave?"), ordinal assessment of the MDMA "high" (ranging from 1 = much worse than you expected it to be to 6 = much better that you expected it to be), and dichotomous (yes/no) effects of current MDMA use (e.g., "In the past 90 days, have you experienced anxiety due to your ecstasy use?" "In the past 90 days, have you experienced hallucinations due to your ecstasy use ?").

We obtained history of MDMA booster doses and binge use via dichotomous (yes/no) and ordinal (ranging from 1 = less than a month to 6 = almost every day) questions. We assessed relationships between MDMA use and attitudes toward music, lighting, and sensory experiences using ordinal scales (ranging from 1 = strongly disagree to 5 = strongly agree). We measured perceived risk associated with MDMA use (e.g., "How likely is it that ecstasy may cause brain damage?" "How likely is it that ecstasy may cause memory problems?") via ordinal scales (ranging from 1 = very likely to 5 = very unlikely).

We also obtained a thorough drug history for alcohol, crack cocaine, powder cocaine, heroin, oxycontin, other prescription pills, methamphetamine, amphetamines, hallucinogens, marijuana, gamma-hydroxybutyrate (GHB), and ketamine. We gathered information related to age of first use to ascertain a time-sequential order of substance use. We also assessed the frequency of use (number of days), quantity used, method of administration (inject, smoke, snort, or swallow), and money (dollar amount) spent on each drug in the last 90 days. We queried about previous substance abuse treatment and counseling and considered specific drugs for which respondents previously sought treatment (e.g., "Have you ever sought treatment or counseling for problems with alcohol?" "Have you ever sought treatment or counseling for problems with methamphetamine?"). We evaluated participants' current views regarding the efficacy of substance abuse treatment by the following question:
   If you wanted to get off drugs would you feel: (a) being in a
   treatment program is too demanding, (b) you have too many other
   responsibilities now to be in a treatment program, (c) it will
   be hard for you to resist drugs or alcohol where you currently
   live, (d) your old friends may try to get you to drink or use
   again, and (e) drug and alcohol treatment just doesn't work.


The seven criteria of the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev., DSM-IV-TR; American Psychiatric Association, 2000) diagnosis for generic substance dependence were assessed via dichotomous (yes/no) questions (e.g., "In the past 12 months, has there been a period when you spent a great deal of time using ecstasy, getting ecstasy, or getting over its effects?" "In the past 12 months, have you often used larger amounts of ecstasy or used for a longer period of time than was intended?"). One point was added to the overall scale for each affirmative answer. The scores could range from 0 to 7, and the scale was found to be reliable (Cronbach's [alpha] = .79). This approach allowed for the trichotomization of respondents into three groups: dependence (positive answers to three or more questions), abuse (one or two positive responses), or recreational use (no affirming answers). Diagnostic assessment for substance dependence other than MDMA use was not conducted.

Statistical Analysis

The main purpose of the analyses was to assess the use of MDMA and other substances, evaluate serf-perception of risk related to MDMA use, and determine attitudes toward substance abuse treatment among a cohort of young adult MDMA users. Analysis started with frequency distributions of sociodemographic characteristics, drug usage, and psychosocial variables. Evaluation of baseline data regarding DSM-IV-TR criteria for substance abuse and dependence allowed for the classification of MDMA users into dependent, abusing, and recreational users. To address Research Question 1, we used Pearson's chi-square statistics to analyze relationships between dichotomous variables (gender, race, sexual orientation, etc.) and dependent, abusing, and recreational levels of MDMA use. We used Fisher's exact test for examining associations with inadequate cell sizes to conduct a chi-square test. To examine Research Questions 2 and 3, we conducted Mantel-Haensezel chi-square analyses to assess the relationship between ordinal variables, such as the perceived risk associated with MDMA use (1 = very unsafe to 5 = very safe, 1 = very likely to 5 = very unlikely), and varying diagnostic categories of MDMA use. If the relationship between the ordinal variables and MDMA use was not linear, we also performed Pearson's chi-square testing. All analyses were two-tailed, and a p value of equal to or less than .05 was considered significant.

Results

Sociodemographic characteristics of respondents are presented in Table I according to classification of MDMA usage. There was no significant difference among recreational, abusing, and dependent young adult MDMA users in age, [chi square] (14, N = 268) = 11.80, p = .62; gender, [chi square] (2, N = 268) = 1.38, p = .50; racial background, [chi square](10, N = 268) = 7.21, p = .71; employment status, [chi square] (6, N = 268) = 3.33, p = .76; or sexual orientation, [chi square] (4, N = 268) = 2.01, p = .73. Therefore Hypotheses I and 2 of Research Question I were not supported. Of the 268 respondents, 84 (31.3 %) reported having been homeless at least once in their life, whereas 31 (11.6%) participants identified themselves as homeless in the previous 6 months. Nearly 3 out of every 10 respondents had dropped out of high school before the age of 18. MDMA dependence was significantly higher in individuals who either reported having dropped out of high school, [chi square] (2, N = 268) = 5.86, p = .048, or acknowledged recent homelessness, [chi square] (10, N = 268) = 18.44, p = .049.

Lifetime prevalence of substance use other than MDMA for respondents was as follows: alcohol (99.2%), marijuana (98.5%), hallucinogens (62.7%), methamphetamine (49.3%), powder cocaine (38.1%), ketamine (35.4%), amphetamine (31.0%), oxycontin (23.5%), GHB (22.8%), crack cocaine (20.1%), and heroin (15.7%). Dependent users of MDMA were more likely to report lifetime use of heroin, [chi square] (2, N = 268) = 6.56, p = .05; methamphetamine, [chi square](2, N = 268) = 6.63, p = .048; and ketamine, [chi square] (2, N = 268) = 6.61, p = .05, than were abusing or recreational users of MDMA (see Table 2). As a result, the only component of Hypothesis I that was supported in this research was the relationship between MDMA dependent users and methamphetamine use. The relationships between MDMA and both marijuana and cocaine were not supported. Compared with lifetime use, there was no significant relationship between the classification of MDMA user and other substance use (including alcohol) in the past 90 days (see Table 3). For example, over 86.0% of all respondents had used marijuana in the previous 3 months; nearly 37.0% had used psychoactive stimulants, such as powder cocaine and methamphetamines; and approximately 3 out of every 10 respondents had used hallucinogens in the same period. On average, respondents' history of illicit drug use began with marijuana (M = 14.34 years of age), followed by hallucinogens (M = 16.66 years), powder cocaine (M = 17.54 years), ecstasy (M= 17.84 years), and methamphetamine (M = 18.16 years). Although no significant differences were found between age of first-time use of any illicit substance and the trichotomous classification of MDMA users, MDMA-dependent respondents did report earlier use of each of the aforementioned drugs than abusing or recreational users. In addition to assessing past and current drug use, we also assessed perceived risk related to MDMA. Nearly half of all respondents (n = 118) viewed the use of MDMA as either unsafe or very unsafe, whereas only a quarter of all participants (n = 68) described MDMA as safe or very safe. Dependent young adult MDMA users were the most likely to describe MDMA use as very unsafe, [chi square] (8, N = 268) = 16.34, p = .05, which thereby supports the hypothesis for Research Question 2. Furthermore, respondents in the dependent category more often viewed MDMA as very likely to cause brain damage, heart problems, vision problems, memory problems, and depression than abusing or recreational users (see Table 4). The overall perception of risk associated with MDMA use was high. At least half of all respondents reported that they believed MDMA may cause memory problems (72.8%), brain damage (67.2%), depression (64.2%), heart problems (61.6%), and death (50.0%).

Attitudes toward substance abuse treatment were also investigated in this sample of MDMA young adult users (see Table 5). A quarter (n = 67) of all respondents reported previous substance abuse treatment, for which the majority had entered an inpatient or alcohol rehabilitation facility (58.2%). Drugs for which participants sought treatment included the following: marijuana (n = 37), alcohol (n = 25), powder cocaine (n = 20), heroin (n = 17), and MDMA (n = 10). Most participants were able to enter drug treatment; however, a majority (52.9%) of those not able to receive

help cited "no treatment for MDMA users" as a primary reason. Nearly 80.0% of respondents (n = 212) disagreed with the statement, "Drug and alcohol treatment just doesn't work," and two thirds (n = 177) of participants did not perceive being in a treatment program as too demanding. Dependent users of MDMA most often cited the influence of social and peer pressure as a hindrance to maintaining abstinence, [chi square] (2, N = 268) = 10.08, p = .006. No significant relationships between varying classification of MDMA user and negative attitudes toward substance abuse treatment were reported. Therefore, Hypotheses 1 and 2 for Research Question 3 were not supported.

Discussion

Substance abuse treatment professionals historically have discounted the severity and negative consequences of MDMA use (Sydow, Lieb, Pfister, Hofler, & Wittchen, 2002). Nevertheless, results from an emerging body of literature highlight the detrimental neurological and physiological effects of MDMA use, especially among young adults. This study is the first population-based examination of young adult users of MDMA focusing on the prevalence of MDMA and other drug use (including alcohol), perceived risks associated with MDMA, and attitudes toward substance abuse treatment. The inclusion of MDMA as a stimulant in the DSM-IV-TR with specific classifications of substance abuse and dependence is justified by the findings of this research. Results from this study indicate that the criteria for stimulant dependence were met for a large percentage of this sample. For example, heavy users reported distinct withdrawal symptoms after MDMA use, greater tolerance to MDMA over time, unsuccessful attempts to cut down or control MDMA use, and consumption of larger amounts of MDMA than originally intended. These findings are supported by the prevalence and use patterns (lifetime and past 90 days) of MDMA in this sample.

Several additional findings that challenge conventional wisdom conveyed in the literature should also be highlighted. First, in contrast to previous claims that MDMA use is mostly experimental (Solowij, Hall, & Lee, 1992), results from this study show that casual or weekend MDMA drug use was not supported for a majority of this sample. Although daily use was rare, lifetime use of more than 100 MDMA pills was not unusual (n = 134; 50.0%) among respondents. Second, MDMA is not limited to young adult White users, as indicated by the ethnic composition of previous studies of young adult MDMA users (Heffernan, Jarvis, Rodgers, Scholey, & Ling, 2001; Milani, Parrott, Turner, & Fox, 2004; Urbach, Reynolds, & Yacoubian, 2002). Only half of this sample self-identified as White, whereas nearly 36.0% of the sample was African American. Although these sociodemographics may reflect the racial diversity found in a southeastern metropolitan area (U.S. Census Bureau, 2000), these results support the epidemiological findings that use of MDMA is spreading into varying ethnic minority groups, especially the African American community (Theall, Green, Kachur, & Elifson, 2001). Third, the perception that MDMA use is limited to rave parties, dance clubs, and circuit parties is unsubstantiated (Boeri et al., 2004; Yacoubian et al., 2003). Use of MDMA at school, work, or home was reported by a majority of respondents. Finally, the opinion that the frequency of MDMA use is higher in the gay, lesbian, and bisexual community than in the heterosexual community also was not supported (Klitzman, Greenberg, Pollack, & Dolezal, 2002; Ross, Mattison, & Franklin, 2003). Heterosexual respondents in this study did not use MDMA more often, nor did they report greater problems associated with MDMA use than did gay, lesbian, or bisexual participants.

Although high rates of other drug consumption among MDMA users were similar to those in previous studies (Darters et al., 2004; Daumann, Pelz, Becker, & Tuchtenhagen, 2001), specific findings from this investigation provide unique insight for treatment professionals working with MDMA users. The high prevalence of marijuana use among MDMA users is not surprising. Conversely, the fact that nearly two thirds of MDMA users reported lifetime use of hallucinogens, which are, on average, consumed by less than 5.0% of young adults (SAMSHA, 2003), is more dramatic. Use of hallucinogens may be a precursor to MDMA use, given that fewer respondents reported use of hall lucinogens in the past 90 days. In addition, although a large number of MDMA users met the criteria for substance dependence, only 20.0 % of respondents identified MDMA as their primary drug of choice. On one hand, these findings support the claim that MDMA can be recognized as problematic by its users and therefore deserves a specific clinical protocol to assist in intervention efforts. On the other hand, higher amounts and frequency of MDMA use were not related to identification of MDMA as the respondent's primary drug of choice. Consequently, substance abuse assessment and screening professionals may not always be able to rely on client self-reports to prioritize problematic use of a drug perceived to possess less stigma than other drugs (e.g., cocaine, heroin, and methamphetamine). These clinicians should include a separate evaluative category for MDMA use and specifically focus on age of first use, progression, current patterns, money spent on the drug, withdrawal symptoms, and tolerance.

Intervention efforts in the last 3 years have attempted to provide education about the harmful effects of MDMA use (Schifano, Leoni, Martinotti, Rawaf, & Rovetto, 2003; Yacoubian et al., 2004). Our findings with this sample of young adults show that these attempts have had mixed results. Results from this study indicate that either education about harmful effects may not be getting to these MDMA users or these participants are choosing to ignore them. Less than half of the sample described MDMA use as likely or very likely to cause harm. Furthermore, MDMA-dependent participants were most likely to cite higher risk in using this drug. Individuals with higher consumption of MDMA might already have experienced memory problems, depression, and anxiety and possibly were more familiar with the drug's negative impact. As research is increasingly supporting the potential short-term and long-term risks of MDMA use, substance abuse treatment counselors need to continue educating clients on its unique dangers.

Reports of admittance to substance abuse treatment for MDMA use were rare. Most respondents who sought previous treatment admission were able to receive either inpatient or outpatient services. What is disturbing, however, is that some MDMA users perceived substance abuse treatment facilities as not providing treatment for MDMA dependence. This finding suggests that MDMA users may perceive treatment facilities as lacking knowledge about MDMA or consider MDMA use to be unworthy of treatment. MDMA users are more likely to enter treatment for problems associated with use of other substances, particularly marijuana, alcohol, and powder cocaine. Yet substance abuse treatment professionals often do not explore how MDMA interacts with other substances, especially marijuana (Daumann et al., 2001).

Despite significant findings, four limitations to our study should be considered. First, all data from this study were collected via uncorroborated self-reports, which might have been influenced by social desirability or the Hawthorne effect. Therefore, we cannot know the accuracy with which respondents reported their involvement with substance use. Nevertheless, previous researchers in the substance abuse field have found high reliability and validity in self-reported data from similar populations (Anglin, Hser, & Chou, 1993; Higgins et al., 1995; Miller, Turner, & Moses, 1990). A second potential limitation relates to recall bias. Respondents were asked to describe alcohol and illicit drug use and an array of beliefs and attitudes in time periods ranging from the present day, to the past 90 days, to their lifetime. We cannot determine exactly how recall bias might have influenced the data. A third possible limitation is the sampling strategy used in data collection. Because all data were obtained from individuals residing in one southeastern metropolitan area, results may not be generalizable to other regions of the United States or to more suburban and rural areas of this southern state. Furthermore, this study is not necessarily representative of all MDMA users in this particular city, because a random sample was not drawn. Interviews were also conducted at various locations, which could enhance standardization concerns. We did, however, recruit participants from diverse settings and at varying times of day to increase the representativeness of the sample. Finally, one cannot ignore the confounding influence of additional substance use, especially marijuana, on this sample. We specifically attempted to isolate the effects of MDMA use. Nevertheless, even when we assessed specifically for MDMA use, it was difficult to determine whether the consequences were a result of MDMA use or were influenced by use of other substances.

Additional research is needed to enable substance abuse treatment professionals to assist more effectively their young adult MDMA-using clients. Longitudinal studies that follow a cohort of dependent, abusing, and recreational MDMA users over time are needed to ascertain short-term and long-term consequences. Assessment of counselors' knowledge of MDMA (e.g., pharmacology and mechanism of action) and its neurological, psychological, and physical impact on the user is also needed. Evaluation of intervention strategies with MDMA users is also recommended, including specific goals and objectives, individual and group paradigms, and effective aftercare planning. Finally, intervention strategies that target at-risk groups of young adults need to be identified, implemented, and evaluated. For example, the Internet, which is commonly frequented by young adults, could be used to elucidate the risks associated with MDMA use as well as to suggest possible treatments.

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Brian J. Dew, Department of Counseling and Psychological Services, Georgia State University; Kirk W. Elifson, Department of Sociology, Georgia State University; Claire E. Sterk, Rollins School of Public Health, Emory University. This research was supported by National Institute on Drug Abuse Grant RO1 DA0143232 and by the Emory Center for AIDS Research. Correspondence concerning this article should be addressed to Brian J. Dew, Department of Counseling and Psychological Services, Georgia State University, PO Box 3980, Atlanta, GA 30302 (e-mail: bdew@gsu.edu).
TABLE 1
Sociodemographic Characteristics of Participants According to
MDMA Using Status (N = 268)

                             Recreational %   Abuse %
Variable                       (n = 46)       (n = 110)

Age
 18-19                        32.6             40.9
 20-21                        26.1             20.9
 22-23                        23.9             20.9
 24-25                        17.4             17.3
Gender
 Female                       28.3             34.5
 Male                         71.7             65.5
Race
 African American             37.0             38.2
 White                        50.0             50.9
 Latino                        0.0              2.7
 Native American               2.0              0.9
 Other                        10.9              7.3
High school dropout (% yes)   17.4             26.4
Ever homeless (% yes)         23.9             29.1
Present employment status
 Full time                    32.6             20.9
 Part time                    32.6             40.9
 Unemployed                   19.6             25.5
 Student (only)               15.2             12.7
Sexual orientation
 Heterosexual                 87.0             79.1
 Gay/lesbian                   8.7             10.0
 Bisexual                      4.3             10.9
Relationship status
 Single                       41.3             39.1
 Separated, divorced           2.2              0.9
 Married                       4.3              0.0
 Living with partner          19.6             11.8
 Steady relationship
  (noncohabitation)           23.9             28.2
 Casual relationship
  (noncohabitation)            8.7             20.0

                              Dependence          p
Variable                      (n = 112)

Age                                               ns
 18-19                        42.9
 20-21                        22.3
 22-23                        12.5
 24-25                        22.3
Gender                                            ns
 Female                       27.7
 Male                         72.3
Race                                              ns
 African American             33.0
 White                        50.0
 Latino                        3.6
 Native American               0.0
 Other                        13.4
High school dropout (% yes)   35.7
Ever homeless (% yes)         36.6
Present employment status                         ns
 Full time                    25.9
 Part time                    35.7
 Unemployed                   23.2
 Student (only)               15.2
Sexual orientation                                ns
 Heterosexual                 82.1
 Gay/lesbian                   8.0
 Bisexual                      9.8
Relationship status                               ns
 Single                       38.4
 Separated, divorced           0.0
 Married                       0.0
 Living with partner          16.1
 Steady relationship
  (noncohabitation)           24.1
 Casual relationship
  (noncohabitation)           21.5

Note. MDMA = 3,4-methylenedyoxymethamphetamine.

*p < .05.

TABLE 2

Substance Use of Participants According to
MDMA Using Status (N = 268)

                        Recreational %    Abuse %
Substance History          (n = 46)      (n = 110)

Lifetime use (% yes)
  Alcohol                    98.3          99.1
  Crack cocaine              17.4          18.2
  Powder cocaine             52.2          58.2
  Heroin                     10.9          12.7
  Oxycontin                  17.4          24.5
  Methamphetamine            43.5          44.5
  Amphetamine                30.4          31.8
  Hallucinogen               63.0          60.9
  Marijuana                  95.7          99.1
  GHB                        19.6          21.8
  Ketamine                   34.8          29.1

Substance History         Dependence
                          (n = 112)          p
Lifetime use (% yes)
  Alcohol                    99.3            ns
  Crack cocaine              23.2           ns
  Powder cocaine             69.6            *
  Heroin                     20.5            *
  Oxycontin                  25.0            ns
  Methamphetamine            56.3            *
  Amphetamine                30.4           ns
  Hallucinogen               64.3           ns
  Marijuana                  99.1           ns
  GHB                        25.0           ns
  Ketamine                   42.0            *

Note. MDMA = 3,4-methylenedyoxymethamphetamine;
GHB = gamma-hydroxybutyrate.

* P < .05.

TABLE 3

Illicit Drug Use by Extent of MDMA Using Status (N= 268)

Substance             Recreational              Abuse
History                 (n = 46)               (n = 110)

                 n       Range     %       n       Range     %

Powder cocaine   12.0     1-90    26.1    34.0     1-75     30.9
Heroin            2.0    14-90     4.3     4.0    15-90      3.6
Oxycontin         2.0     2-5      4.3     6.0     1-6       5.4
Meth.            17.0     1-80    40.0    33.0     1-60      0.3
Amphetamine       3.0     2-90     6.5     7.0     1-90     15.4
Hallucinogen     13.0     1-10    28.2    32.0     1-45     29.1
Marijuana        41.0     1-90    89.1    83.0     1-90     75.4
GHB               4.0     1-21     8.7     6.0     1-5       5.4
Ketamine         10.0     1-8     21.7     8.0     1-12      7.2

                      Dependence
Substance              (n = 46)                  Total
History          n       Range     %       n       Range   %      p

Powder cocaine   52.0    1-35     46.4    98.0     1-90   36.6   ns
Heroin           11.0    1-90      9.9    17.0     1-90    6.3    *
Oxycontin        12.0    1-20     10.7    20.0     1-20    7.4   ns
Meth.            46.0    1-90     41.0    96.0     1-90   35.8    *
Amphetamine      16.0    1-90      6.0    26.0     1-90    9.7   ns
Hallucinogen     32.0    1-43     28.6    77.0     1-45   28.7   ns
Marijuana       107.0    1-90     95.5   231.0     1-90   86.2   ns
GHB               8.0    1-10      7.1    18.0     1-21    6.7   ns
Ketamine         18.0    1-15     16.1    36.0     1-15   13.4    *

Methamphetamine; GHB = gamma-hydroxybutyrate.

* p <.05.

Note. MDMA = 3,4-methylenedyoxymethamphetamine; Range = range of
days used; Meth. = Methamphetamine;
GHB = gamma-hdyroxybutyrate

TABLE 4

Perceived Risk Associated With MDMA Abuse(n = 110)

MDMA Using            Recreational  Abuse
Classification        (n = 46)      (n = 110)

Overall safety (a)    3.08          3.25
Brain damage (b)      1.35          1.30
Sterility (b)         2.17          1.90
Memory problems (b)   1.39          1.15
Heart problems (b)    1.61          1.38
Depression (b)        1.59          1.28
Death (b)             2.04          1.60

                      Dependece     Total
                      (n = 112)   (n = 268)   p

Overall safety (a)    3.53        3.34        *
Brain damage (b)      1.22        1.27        ns
Sterility (b)         2.05        2.01        ns
Memory problems (b)   0.96        1.12        *
Heart problems (b)    1.41        1.43        ns
Depression (b)        1.37        1.37        ns
Death (b)             1.61        1.68        ns

Note. MDMA = 3,4-methylenedyoxymethamphetamine.

(a) Ordinal scale (1 = very safe to 5 = very unsafe).

(b) Ordinal scale (1 = very likely to 5 = very
unlikely).

* P < .05.

TABLE 5

AttitudesToward Chemical Dependency Treatment
by MDMA Drug Using Group

MDMA Using             Recreational           Abuse
Classification          (n = 46)             (n = 110)

                     n          Yes %       n        Yes %

Too demanding        13         28.3       35.0       31.8
Too many
  responsibilities
  to enter           22         47.8       63.0       56.3
Hard to resist
  where currently
  live               12         26.1       43.0       39.1
Old friends may
  urge to use        21         45.7       61.0       55.5
Treatment just
  doesn't work       6          13.0       22.0       20.0

MDMA Using              Dependence            Total            p
Classification          (n = 112)             (N = 268)

                     n          Yes %      n          Yes %

Too demanding        43         38.4       91.0       33.6     ns
Too many
  responsibilities
  to enter           148        55.2       148.0      55.2     ns
Hard to resist
  where currently
  live               47         42.0       102.0      38.1     ns
Old friends may
  urge to use        79         70.5       161.0      60.1     "'
Treatment just
  doesn't work       25         22.3       53.0       19.8     ns

Note. MDMA = 3,4-methylenedyoxymethamphetamine.

** p < .01.
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Title Annotation:3,4-methylenedyoxymethamphetamine
Author:Dew, Brian J.; Elifson, Kirk W.; Sterk, Claire E.
Publication:Journal of Addictions & Offender Counseling
Geographic Code:1USA
Date:Apr 1, 2006
Words:7561
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