MDMA Is One of the Safer Illegal Drugs. But There Are Risks. (2023)

Over the last few years, MDMA, also known as Ecstasy or Molly, has increasingly become associated with therapy and healing and could be approved next year by the U.S. Food and Drug Administration for the treatment of post-traumatic stress disorder. In July, Australia became the first country to make MDMA a prescription medication.

But, like cannabis and other psychedelics, MDMA is also a recreational drug, with an estimated 20 million people around the world consuming it outside of a legal, clinical setting in 2021. National surveys in the U.S. estimate that 7.5 percent of Americans over the age of 12 have tried Ecstasy at least once.

As MDMA moves toward wider medical approval, some experts predict the drug’s recreational popularity will also grow. As happened with cannabis, “MDMA recreational use might piggyback on medicalization,” said Russell Newcombe, an independent drug researcher in Liverpool, England.

In advance of approval, we asked doctors and experts to explain the risks associated with recreational MDMA use and how to reduce them.

What is MDMA?

Methylenedioxymethamphetamine (MDMA) is a synthetic psychoactive drug first developed and patented by the German pharmaceutical company Merck in 1912. After being resynthesized in the mid-1970s by Alexander Shulgin, a psychedelic chemist in the Bay Area, MDMA began gaining popularity among therapists who used it in conjunction with talk therapy.

By the early 1980s, MDMA had become a popular party drug. In 1985, the Drug Enforcement Administration placed MDMA on Schedule I, the list of strictly-banned drugs defined as having no currently accepted medical use and a high potential for abuse. Most other countries followed suit and also criminalized MDMA.

How dangerous is MDMA?

Despite its D.E.A. classification, MDMA is widely considered to be among the safer illegal drugs. Still, taking it outside a clinical setting can still be dangerous. In 2020, an estimated 3,211 MDMA-related emergency room visits occurred around the United States, according to the Substance Abuse and Mental Health Services Administration.

Deaths related to MDMA do happen, although they are far rarer than those caused by a number of other legal and illegal drugs, such as alcohol or cocaine, said Matthew Johnson, a professor of psychiatry and behavioral sciences at the Johns Hopkins University School of Medicine.

No one knows how rare, because reliable data does not exist, said Carl Hart, a neuroscientist at Columbia University. “A great deal of individuals whose deaths are labeled ‘drug-involved’ have multiple drugs in their system, making it difficult to disentangle the effects of one drug from another, including lethal effects.”

Complicating things, the U.S. often lumps MDMA-related deaths together with those of more dangerous drugs. In Britain, where around half a million people take MDMA each year, authorities report an average of about 60 annual MDMA-related deaths — most of which involve additional substances.

The inadvertent risks

Some of the most serious risks of taking MDMA outside a clinical setting stem from the potential presence of adulterants such as methamphetamine and synthetic cathinones (“bath salts”). Fentanyl is not commonly detected in samples sold as MDMA.

“Counterfeit drugs are the biggest risk of MDMA,” said Julie Holland, a psychiatrist in New York City, author of “Good Chemistry,” and a proponent of MDMA therapy. “As long as it’s illegal, you don’t know what you’re getting.”

Without additional testing, it’s also impossible to determine the potency of MDMA in any given sample, which can lead to accidental overdoses. “People have no idea what the purity of it is until it hits them,” Dr. Newcombe said.

The physical risks

Many of MDMA’s health risks relate to the fact that it is an amphetamine derivative, said Matthew Baggott, a neuroscientist and chief executive of Tactogen, a life sciences company developing MDMA-like molecules for medical use. MDMA increases one’s heart rate and blood pressure. It also causes the body to become hotter while simultaneously reducing its ability to release heat.

Because of this, hyperthermia, or overheating, can occur in certain settings, such as clubs where people may dance for hours in a hot environment without taking breaks or drinking water, said Matthias Liechti, a professor of clinical pharmacology at the University Hospital of Basel in Switzerland. Signs of hyperthermia include redness, shivering and a lack of sweating, as well as disorientation. The risk of overheating increases if someone consumes too much MDMA, or if it is mixed it with alcohol or other drugs, Dr. Baggott said.

Another rarer but also potentially deadly problem is overhydrating. This typically occurs when an MDMA user becomes overly concerned about becoming dehydrated, Dr. Johnson said, and starts drinking water “obsessively to counteract that.”

MDMA causes fluid retention, so drinking too much water can lead to hyponatremia, or below-normal blood sodium levels. This, in turn, can cause cerebral edema, a potentially fatal condition in which brain cells swell. Hyponatremia in MDMA users is more likely to occur in women because of additional natural hormonal effects. A 2013 review found 25 reports of Ecstasy-related hyponatremia, almost all of which occurred in women between the ages of 15 to 30, and over half of which were fatal.

There is no consensus on how much water is too much, Dr. Baggott said, but based on research he published in 2016, a dangerous amount could be “about half gallon, if drunk quickly.”

To avoid such problems, users should “drink a bunch of water a few hours before they plan to take MDMA so they start out well-hydrated,” he said. Because MDMA itself doesn’t cause dehydration, once taken, a user would not need extra fluid, he added, only enough to replace what is lost from sweating or vomiting, which sometimes occurs.

The psychological risks

MDMA is not addictive in the same way as drugs like cocaine or methamphetamine, in part because the more frequently a person takes it, “the less it feels good,” Dr. Holland said. But some people do engage in excessive use. People who take MDMA weekly or even monthly sometimes report anxiety, memory problems and depression.

These symptoms usually resolve after the person stops taking the drug frequently, Dr. Holland said. “The rule of thumb is to take it seasonally, only once every three or four months at the most.”

Unlike LSD or psilocybin, MDMA does not typically carry the risk of terrifying mental experiences such as ego dissolution, Dr. Johnson said. But it does sometimes trigger panic and anxiety, and in those who have experienced trauma, it can stir up upsetting memories. “What you call a bad trip on MDMA is generally more emotional despair,” Dr. Johnson said.

MDMA can also cause emotional vulnerability, so users should be thoughtful about where and with whom they take the drug, Dr. Liechti said. “If you’re going to take it, ideally do it with people you know and trust.”

Some recreational users also report a lower mood in the days after taking MDMA, but little research has been done on this. In a study involving 74 healthy volunteers who took MDMA, Dr. Liechti and his colleagues found around one-third of participants experienced “a little bit of a midweek depression,” he said. Scientists suspect that a temporary shortage of serotonin in the brain may be responsible.

Users should be aware “that you might feel awful” in the days after taking MDMA, said Daniel Kruger, a social psychologist at the University at Buffalo. Exercising and eating healthy may lessen the potential comedown, he added, as could doing “things that will bring you joy.”

Rachel Nuwer is a freelance science journalist and author of “I Feel Love: MDMA and the Quest for Connection in a Fractured World.”