JAMA: The drug ecstasy (3,4-methylenedioxymethamphetamine, or MDMA) has been getting a lot of press lately. What specifically should physicians be doing about ecstasy?

Dr Leshner: First of all, they need to understand that it's not a benign substance at all. It's not harmless. It's an incredibly potent stimulant; that's why people love it. It's both a stimulant and a hallucinogen. It causes tremendous increases in blood pressure, heart rate, et cetera. It has a dramatic hyperthermic effect; it increases body temperature tremendously. So it's dangerous in raves [extravagantly energetic dance parties] and situations like that. And it's been shown from a decade of animal research, which is now being confirmed in humans, that ecstasy is toxic to serotonin-containing neurons.

What physicians need to know is that it's dangerous, and that when people come in [with questions about using it], it has to be taken seriously. More and more people are losing control over their ecstasy use. Whether it's truly addicting or not, we don't know. But the fact that they are coming to treatment programs saying, "I can't get control over this" means it has to be taken seriously.

One of the things I'm most interested in is distinguishing between when a compound is a medicine and when a compound is an abusable substance. It can be both, and that is very important for physicians to understand. Morphine is my favorite example, but it's also true of cocaine historically, and it's true of Ritalin [methylphenidate hydrochloride] and a lot of other medications. When used properly under controlled conditions, they're incredibly effective medicines. When misused, they're incredibly addicting.

Now, drugs like ecstasy have been purported to have clinical use, but there's never been a clinical trial demonstrating the efficacy of ecstasy for anything. And the fact that four psychiatrists claim it was useful for them is not evidence (J Nerv Ment Dis. 1992;180:345-52). The plural of anecdote is not evidence."

----------------------------------------------------------------------- COMMENTS FROM HARRY SUMNALL: This last paragraph rather reminds me of the reported exchange between Drs Grob and Ricaurte at the recent SF MDMA meeting and the general paradox of such arguments 1. What about MDMA's clinical utility? 2. No studies have ever been shown which demonstrate MDMA's clinical utility. 3. That's because no studies have ever been allowed to investigate the therapeutic efficacy of entactogens. ------------------------------------------------------------------------

JAMA: Would NIDA support a clinical trial of ecstasy for depression or anything else?

Dr Leshner: We've never received a proposal. If [such a trial] were for a psychiatric therapeutic indication, it would have to go to the NIMH for support. The NIH supports studies on marijuana as a medicine; we support studies on all kinds of things as medicines. There's an awful lot of hype that ecstasy is a medicine, but there's no evidence. And the assertions are not dissimilar to [those made about] LSD [lysergic acid diethylamide] in the '60s and cocaine in the '70s.

JAMA: What you're saying is that the substance itself is not bad, not evil . . . .

Dr Leshner: That's right. It's the way the substance is used. That doesn't mean drug abuse is not bad. The war is not on drugs, the war is not on drug addicts. The war is on drug abuse and addiction, right? That's very important. The reason you want to keep the supply down and the reason you want to control the demand is because you're concerned about the health aspects of it, not because there's something intrinsic in the substance itself. And that nuance, I think, has been hard for people to understand.

If ecstasy turns out to be a wonderful psychotherapeutic drug, let science show that. The assertion that "it saved my life because it gave me great insight" doesn't mean it's true. And the insight could be wrong. The assertion that the insight was terrific is an assertion; it's empirically untestable.