Harm Reduction: MDMA pleasure and Harm Reduction (2): Difference between revisions

This is a continuation of Harm_Reduction: MDMA_pleasure_and_Harm_Reduction_(1) so I suggest reading that :))

Medical aspects

As with any other drug, MDMA is contraindicated in people suffering from certain diseases, as the risk of serious adverse reactions, toxicity or death is much higher than in healthy people.

As a general rule, people suffering from:
• Hypertension
• Heart or liver diseases
• Hyperthyroidism
• Epilepsy
• Glaucoma
• Diabetes
• Immunosuppression

Should refrain from using MDMA. However, a specialist in the subject could assess the risks of a particular patient in certain circumstances. Its use should also be avoided in people with psychological or psychiatric disorders.

It is not clear whether MDMA can affect the fetus or to what extent it eliminates through breast milk, but common sense indicates that pregnant or breastfeeding women should only use those drugs that are strictly essential, and this does not include any illegal drug.

Interactions between different drugs and MDMA are also significant. Many possible interactions exist, but only a few are of practical relevance.

The most serious of these is that between MDMA and protease inhibitors (PIs). PIs (ritonavir, saquinavir, nelfinavir, amprenavir, lopinavir...) are a family of drugs commonly used to treat HIV-AIDS infection. Several cases of fatal intoxication have been reported in people treated with ritonavir (Norvir®) after having used MDMA. Although these persons had consumed regular amounts, extraordinarily high concentrations of MDMA were detected in their blood, since ritonavir does not allow the enzymes responsible for degrading MDMA to work. Thus, people with HIV infection or AIDS being treated with PIs (especially Norvir® and Kaletra® (lopinavir/ritonavir) should avoid the use of MDMA .

Another potentially lethal interaction is that between MDMA and monoamine oxidase inhibitor drugs (MAOIs). MAOIs are a type of antidepressant not widely used at present (only moclobemide (Manerix®) and tranylcypromine (Parnate®) are currently marketed in Europe. MAOIs can also be found in some herbal products (Hypericum, St. John's Wort) and some ayahuasca preparations. Several cases of deaths from the simultaneous ingestion of moclobemide and MDMA have been reported. Another MAOI not marketed in Europe, phenelzine (Nardil ®), can cause very serious intoxications in combination with MDMA.

Other pharmacological interactions are known through theoretical models or anecdotal cases. The simultaneous use of MDMA and β-adrenergic inhalers (drugs used in the treatment of asthma and other respiratory diseases such as salbutamol or terbutaline), stimulants such as methylphenidate are not recommended, although the practical importance of these interactions is much less than those previously described.

There are no known interactions with the contraceptive pill or the most commonly used antibiotics. However, the consequences of MDMA on the immune system could reactivate an infection.

MDMA and sex

Opinions about sex on MDMA vary widely. It is often a matter of personal preference. But, indeed, it is one of the «classical» combinations for sex and drugs. Generally, people prefer engaging in sexual activity 3-4 hours after taking MDMA. At this point, the intense mental effects are beginning to subside, but the sensations of enhanced tactile stimulation and general well-being persist.

One potential issue for men is that MDMA can make it more challenging to achieve and maintain an erection. However, this effect diminishes after three to four hours for most people. Some people counteract this effect using anti-impotence drugs. This is an option in healthy persons and using reasonable dosages.

Although many individuals prefer engaging in sexual activity after taking MDMA, some prefer it during the peak experience. Another common experience for men using MDMA during sex is retarded ejaculation. This can be either an advantage or disadvantage depending on the person and the situation.

Is not just a question of erection: on MDMA you can explore thousands of ways of creative and enhanced sexuality

Disinhibition can have positive aspects (especially if people know each other beforehand and are familiar with the experience). It may be easier to explore fantasies or propose activities we repress in the normal state of consciousness. If we are talking about sex with strangers or people who have not previously experimented with MDMA, things may be different. Maintaining the measures to protect one's health is essential (contraceptives, PREP, condoms…). And also to be aware about self's modified state of consciousness and impact on decisions.

To optimize the experience, looking for an intimate space free of distractions and adopting a good set and setting is best. Showers, bubble bath, massage, porn, erotic talk, fantasies, black light and UV paint, glow sticks, candy….Possibilities are unlimited.

Moderate dosages (no higher than 100-120 mg) are enough. Engaging in sexual activity is no riskier than dancing at a rave (from a cardiovascular point of view), so adding MDMA does not introduce significant differences. Increasing the dose is more likely to result in deep conversation, cuddling, and kissing (which isn't bad either). There are no reported cases of severe toxicity mixing MDMA and sildenafil (Viagra) or similar drugs (Tadalafil, Vardenafil). The combination is probably safe from a pharmacological point of view.

Pre-load and post-load

Pre-loading/post-loading via herbal or pharmacological products with the MDMA is a relatively common practice (up to 40-70% of users, according to some studies) .

5-HTP (hydroxytryptophan) or tryptophan are the most commonly used substances. 5-HTP is the precursor of serotonin, the neurotransmitter allegedly responsible of MDMA psychological effects . MDMA produces a rapid release of a large amount of serotonin in neurons.

However, this release is also believed to be the cause of the acute adverse effects that occur 24-48 hours after consumption. This includes depressed mood and fatigue, as well as the potential neurotoxic effects.

Some users turn to herbal supplements or tryptophan-rich foods to combat these adverse effects: chocolate, peanuts, or bananas. Typical «post-load formulas» contain Vitamin C, magnesium, alpha-lipoic acid or green tea extract.These guidelines are based on recommendations in Internet forums or some books on MDMA.

Pre-loading (before consuming MDMA) seeks to enhance the effects of the substance by theoretically increasing the amount of serotonin available.

Post-loading (after consuming MDMA) aims to help the body recover from the potential adverse effects of MDMA: neurotoxicity, oxidative stress, and depletion of certain neurotransmitters , linked to depression and other adverse effects.

Interestingly, the «midweek blues» have only been reported in recreational users, while therapeutic use has been associated with an «afterglow» in which residual empathogenic effects remain 24-48 hours longer. So this implies that the «crash» of MDMA has more to do with contextual aspects (lack of sleep, physical exercise, mixing with other substances…) than with its pharmacology.

Thus, users who use moderate doses and frequencies, occasionally, programmed and without too many excesses should not suffer very accentuated acute psychological adverse effects. There is also no evidence that, in the usual consumption patterns in humans, MDMA produces irreversible neurotoxic damage. On the contrary, heavy users are more prone to such effects.

So, data to support the use of post-load supplements are based on users' subjective experience. There have yet to be clinical trials that have evaluated this type of strategy. And there needs to be a consensus on appropriate dosages. Some authors recommend «50 mg of 5-HTP for 3 days 24 hours after the last intake». Others use doses of 100-300 mg for 5-7 days.

Post-MDMA intake of bananas, peanuts, or chocolate is unlikely to have any consequence (unless overindulged)

With the available data, it is impossible to recommend a guideline or consider its efficacy. Then, a diet rich in bananas, peanuts, and chocolate is unlikely to have any negative impact after taking MDMA. But it has not been shown to affect either moderate users (in whom it is probably unnecessary) or intensive users (in whom it is probably ineffective for its intended purposes).

Combinations with other drugs

The use of MDMA in combination with other drugs is very frequent, especially in recreational contexts. In general, when MDMA is combined with other drugs, its effects are modified, intensifying certain qualities and diminishing others. Combinations of drugs are generally considered undesirable because they distort the authentic experience induced by ecstasy, as well as increasing the risks. But it is also true that many people seek precisely certain effects from combinations, which can add to the experience. It is very difficult to describe a list of combinations indicating which are "good" or safe and which are not. What for one person may be a desired effect in a certain context, for another may not be. With respect to risks, it is true that drug mixtures introduce an element of greater danger, but as always, factors such as doses, frequencies, contexts and personal characteristics must be assessed. People who are going to mix MDMA with other drugs should be well aware of their characteristics, effects and risks and always use lower doses than those that would be used without the combination. It is necessary to have experimented sufficiently with the substance before deciding to mix it with another, as sometimes the effects may be different from those expected. The effects may also vary markedly if the drug is administered before, at the same time or after the ecstasy. Considering all these factors and as a guideline only, some characteristics of the most frequent drug combinations can be described:

MDMA + alcohol: one of the myths about ecstasy says that its users never consume alcohol and only drink water. But up to 60% of recreational users mix alcohol and MDMA. For many users the combination of MDMA with moderate amounts of alcoholic beverages increases and lengthens the feeling of well-being, decreasing the feeling of sedation produced by alcohol and making the "high" less uncomfortable. At these doses the concentration of MDMA in the body is slightly increased. However for other people the presence of alcohol in the body clouds the mental clarity of ecstasy. Although the feeling of control is greater with alcohol and MDMA than with alcohol alone, the physical faculties (e.g. when driving a car) are objectively impaired. The alterations in the immune system are also more intense and longer lasting. Finally, the consumption of large quantities of alcohol makes the adverse effects on the following day much greater, as well as favoring dehydration.

MDMA+tobacco: The psychoactivity of MDMA is not affected by tobacco use. But compounds in the amphetamine family have bronchodilator properties. This fact coupled with increased perception through the senses can make smoking easier, increasing the number of cigarettes consumed.

MDMA+cannabis: Some users report that smoking cannabis when the effects of MDMA begin to wear off makes the return to normalcy more pleasant and makes it easier to fall asleep. Cannabis also seems to increase the visual component (geometric patterns with eyes closed) of high doses of MDMA. On the other hand, regular cannabis use has been associated with memory impairment. Some of the studies on MDMA and memory suggest that these deficits are more intense in habitual cannabis users.

MDMA+cocaine: Most users believe that the effects of MDMA disappear with the administration of cocaine, predominating the stimulant effects and losing the empathogenic and entactogenic qualities. This combination increases the risks due to physical and mental overstimulation. In high quantities and/or susceptible persons, depressive symptoms in the following days can be very important. As a general rule, snorting coke under MDMA effects is a nice way to ruin the experience.

MDMA+ amphetamines (speed/meth):</strong The comments made about cocaine are also valid in the case of speed. However, some people consider that small amounts of speed combined with MDMA allow for more energy for dancing without the entactogenic qualities being too much diminished. When using this combination it should be considered that the duration of the effects of meth is much longer than that of MDMA, and that overdosing can ruin sleep in the following 12-24 hours. There are also data suggesting greater central nervous system impairment in heavy users of MDMA and speed.

MDMA+psychedelics (LSD, psilocybe mushrooms): Known as candyflipping, the MDMA+LSD combination is intended to harness the qualities of MDMA to guide the acid trip. LSD (and other psychedelics in the tryptamine family such as psilocybes mushrooms) are non-selective amplifiers of mental processes, and the experience with these substances are very sensitive to the previous environment and mental state in which consumption takes place. Theoretically, at least MDMA would put the subject in an ideal mental state for the psychedelic trip, eliminating the fear and anxiety components. This type of experience requires sufficient experience with both drugs separately, an exquisite management of doses and times of administration and a sufficiently controlled environment.

MDMA+2C-B:</strong 2C-B (4-bromo-2,5-dimethoxyphenylethylamine) is a synthetic psychedelic that gained some popularity as a substitute for MDMA when it was outlawed. It is characterized by a shorter duration (4-6 hours) and more controllable and manageable effects for most people than other psychedelics. For some authors 2C-B complements ecstasy particularly well, as it enhances the empathic effects and adds a psychedelic component.

MDMA+ketamine: In recreational settings the use of small amounts of ketamine intranasally can provide a component of dissociation between body and mind that some people find appealing.