In the paper by Gouzoulis-Mayfrank et al (this issue, pp 719–725)1, the authors provide evidence that even moderate use of the recreational drug methylenedioxymethamphetamine (MDMA) may lead to cognitive decline in otherwise healthy young people.

This amphetamine derivative (known widely as ecstasy, XTC, or E, but also as Adam, clarity, or essence) is widely used by young people throughout western Europe and the United States. The popularity of the drug has been enhanced by its close association with particular forms of music and dance venues and, despite well publicised cases of MDMA associated death, by the widely held belief that MDMA is a “safe” drug. Indeed, many users think that with better management the dangers associated with the acute effects of MDMA can be removed.2 3 This is based on the false premise that the danger lies in poor control of environmental temperature and “bad” or adulterated drug, which with better quality control, can be eliminated. As can be seen from the introduction to the paper by Gouzoulis-Mayfrank et al, the scientific literature paints a very different picture, with evidence from animal studies in particular of potent neurotoxic effects of MDMA itself on central serotonergic (5-HT) systems. Although many have vigorously contested the applicability of these results to the human condition, a growing body of data is sufficient to raise legitimate concern that negative consequences of exposure to MDMA, although manifest in subtle alterations in cerebral function in the short term (as described by Gouzoulis-Mayfrank et al), might develop into major deficits over longer periods of time. These may possibly be exacerbated by interaction with normal aging processes, or as a result of exposure to stress4 5 and are likely to include cognitive dysfunction and mood disturbances. Even if these long term effects are confined to particularly susceptible people, the very scale of current usage is such that this could represent a major healthcare problem.

The initial studies indicating the dangers of MDMA were performed over a decade ago. Unfortunately in the intervening years we have experienced a sharp decline in the public acceptance of evidence based on animal experiments, and only now are data emerging from human studies which show clear parallels between the laboratory and clinical experience. Those who have been warning of the dangers of MDMA for some time will take scant comfort from having been proved right.