Testimony of Dr. Julie Holland
Before the United States Sentencing Commission on March 19, 2001
on the topic of
The Proposed Amendment
to Increase Guidelines Sentences Concerning MDMA (Ecstasy)
Judge Murphy, and Gentlemen of the Commission:
Good morning, and thank you for the opportunity
to speak here today.
My name is Dr. Julie Holland. I am an assistant
professor of psychiatry at the New York University School of Medicine. I am also a
psychiatrist working in the psychiatric emergency room of Bellevue Hospital in New York
City. For the past five years, I have worked nearly every Saturday night and Sunday night
on what can only be called the "front line" of mental illness. Like anyone who works in psychiatry, I am acutely
sensitive to the dangers of substance abuse. I have witnessed every kind of casualty of
drug and alcohol use imaginable: psychosis, severe depression, violence, suicide attempts,
homelessness and self-neglect. At least three quarters of the patients I see on any given
shift are exacerbating, if not causing, their psychiatric illness by using alcohol and
cocaine. Less than one percent of these substance-induced psychiatric disorders are
secondary to MDMA use.
Based on my own experience and on the published
data, I can report that MDMA is not a
significant cause of psychiatric crises. I have made it clear to my colleagues and the
doctors I train that I am particularly interested in MDMA-related psychiatric cases, as I
am editing a book on MDMA, and yet I have heard of only three of these cases in the past
two years, out of the thousands of psychiatric ER patients who came, or were brought, to
Bellevue over that period . This is not because MDMA use is uncommon in New York: the "rave" and dance club scene is as
active in New York as it is anywhere in the country.
If Bellevue isn't seeing MDMA casualties, it's because they aren't out
there.
The national data confirm the Bellevue
experience. Eleven percent of high school seniors in 2000 reported having taken MDMA in their lifetimes; the national household
survey reported that 1.4 million people between the ages of 18 and 25 have taken it as
well. Yet neither the medical nor the psychiatric emergency rooms are overrun with the
"ecstasy casualties" one might expect.
According to the Drug Abuse Warning Network less
than one-third of one percent of drug-related emergency room visits in 1999 involved
"Ecstasy" as the reason. By
contrast, 19 percent of drug-related ER visits involved alcohol in combination with some
other drug (alcohol alone is so common that it isn't even counted), and 17 percent were
due to cocaine.
Even the rare MDMA cases tend to be less severe
than the cases involving other drugs. The most common adverse effects from acute MDMA
intoxication are anxiety or panic reactions. Also common among frequent or higher dose
users is a transient depression several days after ingestion. More serious psychiatric
consequences from ìecstasyî use are quite rare.
Not only are MDMA related cases a small
percentage of all drug-related emergency room visits, but a large percentage of MDMA cases
are not life-threatening. In a recent study
conducted by the physicians in the Emergency Department of Bellevue, (Rella, Int J Med
Toxicol 2000; 3(5): 28) regional hospital ecstasy cases phoned into the New York City
poison control center were analyzed. There were 191 cases reported during the years 1993
to 1999 inclusive. This is a rate of fewer than thirty cases per year. 139 cases (73%)
were mild and experienced minor or no toxicity. The most commonly reported symptoms were
increased heart rate (22%), agitation (19%), and nausea and vomiting (12%). In these seven
years, only one ecstasy-related death was reported, which was due to hyperthermia, or
overheating. Ecstasy is simply not the "killer drug" the media would like us to
believe.
Contrast the MDMA-associated morbidity and
mortality with that of methamphetamine, for example. According to the Drug Abuse Warning
Network data, in the five years between 1994 and 1998, inclusive, there were 2,601 deaths
reported secondary to methamphetamine. During that same time period, only 27 deaths were
attributed to MDMA. Compare this 100 to 1 ratio of mortality to the proposed penalties for
methamphetamine and MDMA, a ratio of two to one. In
1999, there were 4,705 deaths recorded attributed to heroin intoxication. In 1999, 9
people died secondary to ecstasy use. Compare this ratio of over five hundred to one, to a
penalty ratio of one to one.
MDMA is less likely to cause violence than
alcohol, less addictive than cocaine or tobacco, and less deadly than heroin. It is also
less deadly than tobacco or alcohol, killing 400,000 and 110,000 Americans respectively
each year. Heroin and cocaine rank first and second when a drug is attributed directly to
causing death. MDMA death statistics are so small, they do not even make the list.
Based on what I have learned over the last
fifteen years, it is my belief that MDMA can be used relatively safely when in a
supervised setting. Clinical research studies utilizing MDMA have been conducted with
minimal adverse effects, supporting the notion that a single therapeutic dose of MDMA is
not intrinsically dangerous. The context and the manner in which the drug is used
contributes substantially to the risks of its use. Hyperthermia, by far the most serious
acute complication of ecstasy use, is only brought about when a person engages in vigorous
activity in an overheated environment without adequately replenishing lost body fluids. In
a clinically controlled setting, MDMA-induced hyperthermia has never been reported.
I understand that initially the commission
proposed that penalties for MDMA be aligned with those for heroin. MDMA should in no way
be equated with heroin. Given the doses per
gram, the proposed increased penalty will equate one dose of MDMA with ten doses of
heroin. There is a much higher potential for physical dependence and addiction with
repeated heroin use, and there is a withdrawal syndrome which typically requires medical
intervention. While tolerance to MDMA has been demonstrated, a withdrawal syndrome has
not, and physically addicted laboratory animals or individuals have not been reported in
the literature. There are those who use ecstasy compulsively which does reflect some
psychological dependence, but these are the minority of users. Repeated use of MDMA
results in less desired effects over time, so there is a built in deterrent to chronic use
for the vast majority.
In addition to being inherently less damaging
that heroin, MDMA is taken by a much safer route of administration. While heroin is
typically injected, leading to potential bacterial and fungal infections as well as the
spread of HIV and hepatitis in those who share needles, MDMA is taken orally with no
associated collateral infections. The biggest difference between heroin and MDMA is the
therapeutic index, or margin of safety. Overdosing on heroin will consistently cause
respiratory depression and death.
MDMA also is not a simple stimulant to be
equated with methamphetamine. MDMA has roughly one tenth the stimulant potency of
methamphetamine, and its pharmacological mechanism of action is substantially different.
Patterns of chronic use and dependence that are seen with methamphetamine are not seen
with MDMA.
MDMA also should not be equated with cocaine,
whether in powder or base form. The bulk of the patients I see in the psychiatric
emergency room are either psychotic from chronic cocaine use or severely depressed and
suicidal from withdrawal. These people have frequently spent every penny they have on
buying more and more crack, and are typically unemployed and homeless as a result.
Although there are clearly many people who are taking too much ecstasy too frequently,
they are simply not anywhere near the dire situation of these cocaine addicts. The
penalties for MDMA distribution do not belong between those for heroin and cocaine. The
guidelines for sentencing should reflect the danger of MDMA and the potential damage to
people's lives that it can cause. I see alcoholics and crack addicts every time I go to
work. The psychiatric and medical emergency rooms are overrun with these casualties. I do
not see people whose lives have been ruined by MDMA.
It is my firm belief that people who are abusing
drugs need to be educated and treated within the health care system. Behavioral change and
improved self-care will not result from incarceration. Also, please consider the
unintended public health consequences from stiffer penalties: this will increase the
likelihood of drug substitutes flooding the market, which will increase the potential risk
from drugs which are more likely to cause hyperthermia and death, alone, or in combination
with MDMA, such as dextromethorphan and paramethoxyamphetamine (PMA).
In closing, I would like to note that the
conclusions I have reported are widely shared within the community of experts on drug
abuse. The statement submitted to this
Commission on behalf of the Federation of American scientists reflects what I would
consider the consensus view. Its signers
include Dr. Charles R. Schuster, who was Director of the National Institute on Drug Abuse
during the Reagan Administration, and one of the nation's leading psychopharamacologists,
and Dr. Jerome Jaffe, who as director of the White House Special Action Office on Drug
Abuse Prevention in the Nixon Administration served as the nationís first "drug
czar." They, along with a dozen other
experts, find that there is ìno rational basisî for the proposed treatment of MDMA as on
a par with heroin, weight for weight. I hope
that the Commission will give that statement the weight to which it is entitled due to the
cogency of its argument and the credentials of its signers.
I would respectfully request that the commission
reconsider their proposal to increase the penalties associated with MDMA. I believe that
there is little scientific justification for the severity of these proposed penalty
increase.
Thank you for your consideration in this
important matter.
Julie Holland, MD
Clinical Assistant Professor of Psychiatry
NYU School of Medicine
Attending Psychiatrist, Bellevue Hospital
New York City
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