Some years ago, I was consulted by a young man who wanted advice about the recreational drugs he was taking.
I listened, tried to understand his concerns and referred him to the local drug service. As he left, he said: 'I know more about drugs than you do.' He was right.
Primary care focuses heavily on opiate users. There are sound reasons for this but I concluded that I should know how to give harm reduction advice to all patients who misuse substances.
MDMA use has been stable over the past decade. Findings from the 2007/8 British Crime Survey show that 3.9 per cent of 16 to 24-year-olds reported using MDMA in the past year. Among clubbers this figure rises to 80 per cent.1
Ecstasy or 3,4-methylenedioxymethamphetamine (MDMA) was patented early in the last century.
Since being outlawed in the 1980s because of the possibility of brain damage, MDMA has re-emerged as a commonly used party drug.
MDMA usually comes as brightly-coloured tablets with logos. It is known by a variety of terms, such as E and XTC, and costs about £5 per tablet. It may also be snorted, as it is sometimes available in powder or crystal form.
MDMA is a mildly hallucinogenic psycho-stimulant with its own distinctive effects.
These include facilitation of interpersonal relationships, enhanced empathy, euphoria and an increase in energy.2
Somatic symptoms include mydriasis, jaw tightening, nausea, sweating and dry mouth. MDMA use causes increases in BP and heart rate.
Class A drug
It is illegal to possess or supply MDMA, which, along with cocaine, hallucinogens and opiates is a Class A drug.
The evidence behind the classification of drugs has been questioned by experts. They have proposed a more rational approach to both legal and illegal drugs, according to the risks generated. This system ranks MDMA as less harmful than opiates, cocaine, alcohol, tobacco and cannabis.3
Negative experiences, such as anxiety, confusion and unpleasant distortion of the senses, are more likely if users take high doses or have existing mental health problems.
Research suggests that prolonged use of MDMA raises neurotoxicity, leading to memory deficiency and depression.
MDMA accounts for less than 1 per cent of drug-related deaths. In 2008, it was associated with 12 deaths and contributed to a further 33 cases in users who combined MDMA with other substances.4
Hot environments and hyperactivity are important contributory factors increasing the risk of hyperpyrexia. This in turn can lead to convulsions, cardiac and renal failure, disseminated intravascular coagulation and rhabdomyolysis.
Fluid overload has been associated in a number of deaths. Some of these are due to excess intake, although inappropriate secretion of antidiuretic hormone can occur.
Impure MDMA may contribute to morbidity and fatalities. In Holland, clubs offer testing kits, which have been show to reduce harm.5
MDMA use is not impacting on GP services to any great extent. Yet, early evidence suggests that young people would benefit from brief advice.6,7
GPs should ask leading questions to identify users, such as in standard smoking interventions. Once a rapport has been established, and confidentiality assured, ask the patient whether they use any other substances. If they disclose MDMA use, GPs should give the following harm reduction advice:
- Wear cool clothes for dancing to avoid over heating.
- Don't drive.
- Drugs are not quality controlled; you never know what's in them.
- Do not mix any drugs, including alcohol.
- If you do take more than one drug remember all the effects mount up. This includes prescribed medication.
- Drugs make you feel more confident sexually, but always practise safe sex.
- Make sure you are with friends and tell each other what you are taking so you can help each other if necessary.
- If someone is getting anxious, keep them cool and calm. Stay with them and send a friend for help.
- Learn basic first aid skills with St John's Ambulance.
- Do not drink more than a pint of water an hour to replace lost fluids.
- Look out for symptoms, such as dizziness, feeling sick, headache or cramps.
- Do not use heroin, diazepam or temazepam to take the edge off your come down. A dependence could develop, which would have consequences.
- Attend official, well-run clubs. They should have free, unrestricted access to cold drinking water, adequate ventilation and a separate area to relax. They should have at least one first aider on site and allow drug workers inside.
Finally, it is important to direct patients to the following resources:
GPs who wish to learn more about working with drug users should contact RCGP substance misuse management at www.smmgp.org.uk for details on courses, publications and training.
Dr Thomas is a GP in Swindon, Wiltshire
1. UK Home Office. Drug Misuse Declared: Findings from the 2007/08 Crime Survey, Oct 2008.
2. De la Torre R, Farre M, Roset PN et al. Human pharmacology of MDMA: pharmacokinetics, metabolism and disposition. Ther Drug Monit 2004; 26 (2):137-44.
3. Nutt D, King L, Saulsbury W, Blakemore C. Development of a rational scale to assess the harm of drugs of potential misuse. Lancet, 2007; 369, 9566: 1047-53.
4. National programme on substance abuse deaths annual report, 2009. St Georges' Hospital Medical School.
5. Kriener H, Billeth R, Gollner C et al. An inventory of on-site pill-testing interventions in the EU. European Monitoring Centre for Drugs and Drug Addiction, 2001.
6. Marsden J, Stillwell G, Barlow H et al. An evaluation of a brief intervention model for use with noninjecting stimulant users. National Treatment Agency for Substance Misuse, Nov 2004.
7. Peters G, Kok G. A structured review of reasons for ecstasy use and related behaviours: pointers for future research. BMC Public Health 2009, 9: 230.