Clinical Textbook of Addictive Disorders 3rd ed - R. Frances, S. Miller, A. Mack (Guilford, 2005) WW

164 III. SUBSTANCES OF ABUSEAlthough for an organic chemist, the synthesis of MDMA is reasonablysimple, most supplies in the United States are imported and then distributed byorganized crime networks. Its price, usually $25–40 for a 125-mg tablet, theamount producing the sought-after effect in most intermittent users (Green,Cross, & Goodwin, 1995), has remained remarkably stable over the past twodecades. This high price makes adulteration attractive to the criminal element.Such adulteration can be dangerous when the substance used is something thatis physiologically dangerous. Paramethoxymethamphetamine (PMA) has beensold as MDMA, and in those unfortunate enough to consume both substances,appears to be highly dangerous.Physiological EffectsMDMA is almost exclusively available in pill form. Often the pills are stampedwith clever images. The usual single dose is 100–150 mg. The onset of effectbegins about 20–40 minutes after ingestion and is experienced with immediacy.Often this “rush” is accompanied by nausea and an urgent need to defecate(disco dump).The plateau stage of drug effects lasts 3–4 hours. The principal desiredeffect, according to most users, is a profound feeling of relatedness to the restof the world. Most users experience this feeling as a powerful connection tothose around them, as well as to the universe (Leister, Grob, Bravo, &Walsh, 1992). Although the desire for sex can increase, the ability to achievearousal and orgasm is greatly diminished in both men and women (Buffum &Moser, 1986). MDMA has thus been termed a sensual, not a sexual, drug.The prescription drug sildenafil (Viagra) may be taken in order to counteractthis effect, and may be sold along with MDMA (Weir, 2000); the successormedications involving sexual enhancement can be expected to be used inthis manner. The array of physical effects and behaviors produced by MDMAis remarkably similar across mammalian species (Green et al., 1995) andincludes mild psychomotor restlessness, bruxism, trismus, anorexia, diaphoresis,hot flashes, tremor, and piloerection (Peroutka, Newman, & Harris,1998).Aftereffects associated with MDMA are common and can be pronounced.People using MDMA once, or on multiple occasions, may experience any numberof symptoms, including lethargy, anorexia, decreased motivation, sleepiness,depression, and fatigue. Combining MDMA with PMA has been associatedwith a number of serious adverse events and deaths (Ling, Marchant,Buckley, Prior, & Irvine, 2001). Another acute adverse event, hyponatremia,followed by seizure and coma, appears be a result of the law of unintended consequences.The “harm reduction” admonition of advising MDMA users toadopt the strategy of ingesting copious amounts of water prior to and while takingMDMA appears, in some instances, to have backfired and has caused these