Carpenter C. Saved from Ecstasy: A Multi-partite Intervention for First Time and Repeat Users of 3,4-methylenedioxymethamphetamine (MDMA) Within The LGBTQ+ Community.Harvard Public Health Review. 2021; 41.
According to the National Survey on Drug Use and Health, in just 2014 alone, over 17 million persons ages 12 or older reported at least a singular lifetime use of the hallucinogenic stimulant, and well-known recreational drug, MDMA, or 3,4- methylenedioxymethamphetamine. Compared to 10 years prior, this was an increase from 11 million people within the same age bracket.21Per the European Centre for Drugs and Drug Addictions (ECDDA), 13.5 million individuals ages 15-64 have used MDMA sometime in their lifetime.16
Driven by the desire to perceive its pleasurable effects, MDMA, otherwise known as “Molly” or “E” or “Ecstasy” or the “hug drug”, MDMA users utilize the drug for an enhanced sense of well-being, emotional warmth, increased extroversion, heightened empathy, as well as augmented sensory perception.21,23
However, there are a number of negative side effects associated with MDMA, including (a) hypertension, (b) faintness, (c) panic attacks, (d) loss of consciousness, (e) seizures, (f) involuntary jaw clenching, (g) appetite diminishment, (h) depersonalization, (i) illogical and disorganized thoughts, (j) restless legs, (k) nausea, (l) hot flashes or chills, (m) headaches, (n) muscle or joint stiffness, and (o) malignant hyperthermia and hyperpyrexia. Repeated use or binging of MDMA can cause cardiac arrhythmias, depression, impaired attention and memory, anxiety, sleep disturbances, aggression, impulsivity, and irritability. The danger of MDMA often occurs when individuals overexert themselves (like with dancing) or use it with other substances (such as alcohol, caffeine, or cocaine), at which point the likelihood of overdose, multi-organ damage, and cerebral edema increase.1-6,9,17,21,23,31
In 2011, drug-related emergency department visits related to MDMA complications were estimated at 22,498.21 In 2018, the Annual Report of the American Association of Poison Control Centers’ National Poison Data System reported 183 MDMA-attributable fatalities. It is estimated that approximately 2 of 100,000 MDMA users will be killed by the drug in any given year.31
Use of MDMA has been demonstrated to be higher amongst males, urban-dwelling individuals, and members of the LGBTQ+.31
This proposed intervention – Saved from Ecstasy– seeks to provide a blueprint for preventing morbidity, mortality, and disability associated with the use of MDMA for first time and repeat users within the LGBTQ community. It transcends mere abstinence-only drug campaigns and interventions by combining the principles of harm reduction, behavioral design, and structural re-engineering to catapult public health responsiveness to MDMA to an entirely different level.
In general, there is a plethora of research demonstrating that individuals within the LGBTQ community are at increased risk for alcohol, drug abuse, and other substance abuses compared to their heterosexual counterparts.12,14 For instance, bullying, societal harassment and discrimination, and other stigmatizing experiences are predominant risk factors which precipitate LGBTQ individual’s likelihood of engaging with illicit drugs. According to the minority stress model, stigmatization that arises from multi-level areas – namely interpersonal interactions, organizational and community engagements, and intrapersonal stressors – all elevate the risk for LGBTQ adolescents and adults in engaging in risky substance abuse behaviors. This relationship is typically mediated by the internalized stressors and stigma of being in a hostile environment; expecting rejection and discrimination; experiencing rejection and discrimination on a direct or indirect basis; and experiencing microaggressions, microassaults, or microinvalidations toward their sexual identity. Furthermore, for those LGBTQ individuals who conceal their sexual minority status, there can be a spectrum of consequences in the cognitive, emotional, and behavioral dimensions. This includes obsession or rumination over LGBTQ+ -related stigma and stigmatizing experiences, avoidance of social activities and imposed self-isolation, and manifestation of anxiety and depression. All of these risk factors directly feed into coping mechanisms such as substance abuse.12,14
Some research has postulated that appreciable participation in LGBTQ communal events leads to heightened substance abuse due to the venues which are associated with heavy drinking and substance use.12,14However, this research is mixed.
According to other studies, a higher level of outness and LGBTQ community engagement are risk factors for higher alcohol and drug abuse in bisexual women compared to lesbians. The rationale for this finding is that bisexuals experience “bi-negativity”, or discrimination, stigmatization, and invalidation from both homosexual and heterosexual communities, which can negatively impact their sense of well-being and sexual identity development. As a means of self-soothing, bisexual women are thought to engage in excessive substance use.12
There are numerous studies that suggest that disclosure of one’s sexual orientation is a protective factor. This protective effect is hypothesized to come from closer bonds and connections that LGBTQ people have with one another as well as supportive allies. Those LGBTQ individuals who have reported high levels of community connectedness—via LGBQ youth-serving organizations, LGBQ events such as Pride parades, LGBQ-friendly services, anti-bullying practices, supportive school staff and climate – also tend to have greater psychological and social well-being. Moreover, LGBTQ adolescents who attend secondary and post-secondary schools with gay-straight alliances tend to have lower cigarette use, alcohol consumption, alcohol-related problems, and illicit drug use. Furthermore, other broad-based protective factors have been identified in the research: nurturing religious climate, higher concentration of same-sex couples in one’s region, supportive local public opinion, and presence of anti-hate legislation and laws.12,14
There are also studies which suggest an opposite idea as well: concealment of one’s LGBTQ+ sexual and/or gender identity can be protective, as the exposure to discrimination and stigmatization is decreased, and mental health is preserved and potentially protected.14
Hence, possession of more of these protective factors lessens engagement with harmful and risky substances as a coping mechanism of depression, anxiety, and self-hatred related to a stigmatized and marginalized LGBTQ+ identity.12,14
The settings for the proposed intervention would be night clubs/rave outlets and other predominantly LGBTQ+ entertainment venues which service LGBT American youth ages 18-22 at least once a week. These settings are optimal for the intervention since these are the areas in which LGBTQ youth are more likely to frequent, and utilize and potentially succumb to the negative effects of MDMA.21
The intersectional risk environment framework(see Figure 1) for people who use substances will be an appropriate framework for the Saved from EcstasyIntervention. For researchers conducting substance use research, this particular framework has been the most widely utilized ecological model (see figure 1). It moves beyond focusing merely on individual aspects that heighten one’s risk for substance abuse (e.g., age, sexuality, gender, class, race, ability, citizenship status), and incorporates the need for interventions at the policy, social, physical, and economic levels over a continual and cyclical period of time.7
This framework will be utilized alongside an intentional harm reduction philosophy, which will embed the following tenets into the intervention: (1) acceptance of MDMA use as a regular part of the world, (2) MDMA use as complex and multifaceted, (3) the well-being of MDMA users is more important than mere abstinence, (4) using a non-coercive and non-judgmental approach to MDMA use, (5) representing the voices of MDMA users in MDMA programs and policies, (6) empowerment of MDNA users with information and support, (7) recognize risk-augmenting inequities and inequalities that exist within MDMA users (8) acknowledgement that harm reduction policies are meant to minimize, but ignore or disregard the danger of MDMA use.20
Together, the intersectional substance use model underpinned by a harm reduction modus operandi will be appropriate for the reduction of negative side effects for LGBTQ adolescents/young adults who utilize MDMA. See section on Saved from Ecstasy: A multi-partite, multi-level intervention for more details of how the framework will be tailored to the intervention.
Previous harm reduction interventions for MDMA include: (a) users buying onlyfrom their regular dealer; (b) users onlyusing MDMA from the same “batch” as trusted friends; (c) users consuming the drug initially in small amounts; (d) dissemination of accurate information and drug education regarding the potential dangers of MDMA (e) emphasized material on the pharmacological, physiological, and neurological effects of MDMA; (f) education on the risk, warning signs, and consequences of MDMA-induced dehydration; (g) education on the risks of polysubstance use with MDMA; (h) safety oversights (e.g. amnesty boxes for drug discarding); and (i) pill testing on-site and off-site a given venue, and (j) personal MDMA test kits.1-6,25
Even the Beckley Foundation, which has been a premier national organization at the vanguard of international drug policy reform, has made proposals for potential interventions for MDMA, which include (1) re-scheduling MDMA from a class 1 drug to a lower class, (2) de-criminalizing possession and usage of MDMA, (3) rolling out comprehensive MDMA-checking practices in a variety of venues, (4) restricting manufacture of MDMA to certain pharmaceutical companies in order to guarantee purity and safety of MDMA substances, (5) requiring personal licenses for MDMA users, and (6) developing MDMA-friendly spaces which may either be single substance-use or alcohol-free spaces. Yet, these proposals have not been implemented thus far.30
The Saved from Ecstasy intervention, however, is unique from these previous attempts or proposition. It takes inspiration from the educational campaigns that have been presented before in the late ‘90s and early 2000s and digitizes and contemporizes them. It also builds off of the efforts of organizations that have created apps designed to teach people about safe drug use, such as The Loop and Rave It Safe.24,32
At the policy and economic levels, there will be a need for promotion of various harm reduction techniques regarding MDMA usage. Initially, congressional and/or multi-state commissions can investigate the unintended consequences of abstinence-only MDMA education, programs, and policies. Relative comparisons can then be made with the metrics of safe usage education. The benchmarks can be in terms of emergency department visits, and rates of MDMA-related morbidity, disability, and mortality.
Utilizing principles garnered from behavioral economics and choice architecture, policy can mandate structural re-engineering of clubs, raves, and other entertainment venues which have cooling mechanisms and temperature detection devices, either crafted within the architectural design or provided as ancillary product. Cooling mechanisms and temperature checks can be designed and situated next to the bar, the restrooms, as well as interspersed throughout the dance floor, inevitably nudgingpartygoers to encounter them. Cooling mechanisms can take the form of high-pressured air conditioning or mist streams. Temperature checks may be variant, in the form of wall-mounted temperature gauges or full body temperature scans. Accessory items for cooling and temperature-checking can take the form of LGBTQ+ pride smart wrist bracelets, vests, biometric temperature-monitoring apps, or other intelligent wearable devices that are sold regularly via Amazon or other major retailers.1-6
There is also an imperative for mandates for MDMA detection and response training at regular and major events with a significant youth LGBTQ+ population. For instance, before major PRIDE events – which occur throughout the year in various cities around the world – there will be required training of all personnel in appropriately preventing, recognizing, and responding to individuals who appear to be suffering from malignant hyperthermia, hyperpyrexia, and/or hyponatremia – all grave side effects of MDMA usage. These individuals would function as MDMA lifeguards, not unlike beach lifeguards trained to recognize and respond to drowning, or CPR-trained individuals trained to implement life-saving breaths and compressions for unresponsive persons. Mandatory certification and re-certification can be instituted at the policy level.
Financial incentives will be both sufficient and necessary for these venues to erect these mechanisms and undergo training. Easily and readily accessible grants and funds can be earmarked by Congress. Additionally, there should be architects and other consultants available that can guide entertainment venues through this process. Pre-made training curricula should be downloadable in print and multi-media form from federal and state websites.
There will be a need for an educational component as well. Thus, there will be mandatory point-of-entry educational kiosks or apps that partygoers must engage with for at least 5 minutes and then take and pass an MDMA safe-use test. The app and kiosks will provide easy to understand information about the pharmacological and physiological mechanisms of MDMA, the typical and atypical side effects, as well as ways to prevent and curtail the negative consequences of hyperthermia, hyperpyrexia, and hyponatremia.1-6These apps can be simulated or directly borrowed from organizations such as Drugsdata.org, The Loop, Safeparty, Dancesafe.org, Drug detection labs, and Rave it Safe.8-11, 24,26, 32
In the pre-implementation phase of this smaller experiment, a needs assessment and goal-setting assignments can be established. For instance, on average, what needs(e.g., resources, finances, personnel, etc.) do the small versus medium versus large venues have in terms of implementing the multi-pronged intervention (e.g., educational kiosks, temperature-checks, and cooling mechanisms)? What are the constraintsand enablersto implementation? Who are the relevant stakeholders?
Additionally, the intervention can be evaluated in terms of the following metrics captured by surveys or electronic data:
Similar to the pertinent metrics collected in the pilot, the following information will also be collated during scaling in more venues:
*Measurements of abstinence will also be worthwhile to collect. While the intervention is designed for harm reduction in first time and repeat users, it may nonetheless prompt a certain percentage of individuals to abstain from usage. This will then be invaluable to compare how harm reduction techniques compare to abstinence-only techniques in prompting abstinence from MDMA usage.
In order to prepare for implementation, it will be necessary to enlist the help of local, regional, state, and/or federal partnerships. Targeting LGBTQ+ organizations can help in the social and financial support of these efforts. Additionally, substance use organizations at the state and federal level can earmark monies and supply grants and loans for these visionary endeavors. Unnecessary bureaucracies, regulatory and environmental hurdles, and political opposition will need to be addressed and destabilized. The full endorsement and encouragement of varying models of implementation for this intervention will increase its effectiveness (e.g., supporting architects in design and re-design of venues, sharing best practices, studying failed implementation efforts).
Critical stakeholders will include LGBTQ+ American youth (MDMA-users and non-MDMA users), parents of LGBTQ+ youth, LGBTQ+ supportive organizations, college campus representatives (e.g., from mental health and substance use services, deans, etc.), emergency medicine physicians, family medicine physicians, internal medicine physicians, public health practitioners, drug-testing companies, MDMA treatment and rehabilitation centers.
Engagement, partnership, and sponsorship with as many of the following organizations as possible –like the Office of National Drug Control Policy, Substance Abuse and Mental Health Services Administration, National Institute on Drug Abuse (NIDA), and National Harm Reduction Coalition, Department of Justice, Federal Drug Administration, Centers for Disease Control, and Human Health Services – will spur the successful implementation of this intervention.20,22,28-29All of these stakeholders would likely possess a high willingness to participate, as they intersect with the problem in varying ways. However, I do anticipate that LGBTQ+ youth may feel unnecessarily targeted or worried about stigmatization with research; thus, the research would need to be conducted sensitively.1-6
Long term outcomes will be monitored vis-à-vis annual survey measurement and medical database review to ensure the following:
Paramount to the success of the Saved from Ecstasy intervention will be the key said changes in policy, multi-level and multi-organizational partnerships and sponsorships, and funding streams.
Barriers to the intervention also include conservative, pro-abstinence, and anti-harm reduction policymakers and lawmakers who believe that these steps will be inherently encouraging drug use.1 For instance, theReducing Americans’ Vulnerability to Ecstasy Act(aka The Illicit Drug Anti-Proliferation Act), which threatened entertainment venues with fines as much as $250,000 or imprisonment for 20 years if MDMA was caught or suspected on the premises, dissuaded entertainment venues from utilizing harm reduction techniques (including education) for fear they would be accused of implicitly endorsing MDMA use. Other damaging conservative legislation has prohibited widespread dissemination of educational materials on MDMA or drug-testing.25These are all highly problematic and may pose a threat to the Saved to Ecstasy intervention.
However, there may be a few workarounds. Firstly, the educational apps regarding MDMA already exist in a mobile form and are not prohibited. Secondly, structural re-design of clubs with temperature-checks and cooling mechanisms can also be utilized to reduce and mitigate the potential risk of heat exhaustion and heat stroke that can occur in partygoers, regardless of whether they use MDMA or not; hence, their implementation can be further argued to not be an implicit endorsement of illicit drug use. Thirdly, MDMA lifeguard certification is akin to training in alcohol poisoning that most club personnel undergo, as well as CPR training or beach lifeguard training for drowning. Those trainings are not an endorsement that people will be poisoned or drowned or become unresponsive, but rather a sophisticated and compassionate acknowledgement that certain environments have increased risks of certain life-threatening occurrences and it is important to be prepared for them.
Dr. Carpenter is a physician, entrepreneur, educator, and social justice advocate. She is currently the Co-Editor-in-Chief of the Harvard Public Health Review.