A version of this article was originally published on LinkedIn.
I first made comparisons of the annual mortality rates associated with the use of ecstasy and other activities in articles I wrote in the 1990s. In the following decade, Professor Nutt’s work brought far more media and other attention to these issues – notably his statement that ecstasy was statistically no more dangerous than horse riding.
My main goal was to stimulate debate and research on these issues, because so little research was (and is) being done to investigate them. Death is undoubtedly the most harmful consequence of using ecstasy or other drugs, and if we are to reduce such deaths we need to know much more about their nature, prevalence, and causes.
Based on the annual reports of two UK government departments, the total number of deaths associated with use of ecstasy (MDMA) in the UK in 2015 was 72 – including 57 in England & Wales (the second highest reported number after 58 in 2005) and 15 in Scotland. These figures do not include ecstasy-related deaths in Northern Ireland because they have not been released at the time of writing – though there were 7 such deaths in 2014, the highest annual number ever reported (equalling the number for 2005).
Focusing on England & Wales, annual mortality rates among ecstasy users can be calculated using estimates of the prevalence of illicit drug use from the Criminal Survey for England & Wales (CSEW), a household survey conducted every year by the Home Office. The CSEW estimated that 492,000 adults (16 to 59 year olds) last-year users of ecstasy in 2015/16. As noted above, there were 57 ecstasy-related deaths in England &Wales in 2015 – about one a week (though this excludes the 10 deaths attributed to PMA/PMMA tablets, which were probably sold as ecstasy). This works out as one ecstasy death per 8,632 last-year users of ecstasy. Expressed as a standard mortality rate, this is almost 12 deaths per 100,000 last-year ecstasy users – equivalent to 116 deaths per million last-year users.
But these figures are based on deaths associated both with ecstasy use alone and with ecstasy used with other drugs. The number of deaths in England & Wales involving ecstasy only in 2015 was 24 (about one every two weeks). This is one death involving ecstasy only for every 20,500 last-year ecstasy users – equivalent to almost five deaths involving ecstasy only per 100,000 last-year ecstasy users.
Estimates of the mortality risk of ecstasy use are dependent not only on what deaths are counted as cases of ‘ecstasy-related death’ (the numerator) but also on what figures we use for the prevalence of ecstasy use (the denominator). For instance, if we change our denominator to lifetime prevalence of ecstasy use in 2015/16 (3,077,000) the ecstasy-related mortality rate would be one ecstasy-related death for every 53,982 lifetime users – or a standard mortality rate of almost two ecstasy-related deaths per 100,000 lifetime ecstasy users (or about 19 per million).
Furthermore, to make a more accurate assessment of the mortality risks of ecstasy use, the frequency and intensity of ecstasy use (how many times it is used and how much is used) need to be considered alongside prevalence (how many people use it). These factors are components of my CAMP-MAP theory of harm-reduction (see references below). For instance, focusing on the frequency of use, research indicates that the average ecstasy user consumes it once or twice per year (though a notable minority use it weekly to monthly). Based on the once-a-year frequency of ecstasy use, the mortality rate for episodes of use is the same as the rate for individuals. Based on the average frequency of ecstasy use of twice a year, there was one ecstasy-related death across every 17,264 episodes of ecstasy use in 2015 – equivalent to almost six ecstasy-linked deaths per 100,000 episodes of ecstasy use (or almost 58 ecstasy-deaths per million episodes).
How does the mortality risk of ecstasy use compare with the mortality risks of other activities and experiences – notably other leisure activities? Working with the mortality rate of one ecstasy-related death per 8,632 last-year users of ecstasy in England & Wales in 2015, this would be classified as a ‘medium risk’ (mid-point) in my Risk Assessment model for comparing the annual mortality risks of different leisure, occupational and other activities.
In short, the annual mortality risk of using ecstasy is equivalent to the risk posed by motor sports, water sports, mountain hiking, being a road user, giving birth, liposuction, taking anti-depressants and being in police custody. The mortality risk faced by ecstasy users is also a level lower than the risk associated with drinking alcohol, snorting cocaine, air sports, mountain climbing, motorcycle racing, air pollution, and having medical treatment (a ‘quite high’ annual mortality risk level of around one in 1,000); and two levels lower than the risk associated with smoking tobacco, drug injecting, base jumping, and having surgical operations (a ‘very high’ annual mortality risk level of around one in 100).
However, it must be noted that there are many other factors which need to be taken into account when assessing the mortality risks of using ecstasy and other drugs, and this brief article is intended only to give a broad picture of these issues. These factors range from genetics (e.g. around 1 in 10 people have livers which predispose them to reacting ‘badly’ to ecstasy) to the setting of ecstasy use – notably nightclubs, where contextual factors like ambient temperature, crowding, vigorous dancing, and restricted access to water contribute to the sub-group of deaths involving heat-stroke/exhaustion.
So, in broad statistical terms, that’s how safe ecstasy use is – or how lethal it is, depending on how you look at it. Research has also identified non-fatal risks associated with ecstasy use, including harmful effects on mood and memory – though potential benefits of ecstasy use have been identified too, including experiencing altered states of consciousness involving improved empathy, communication and positive emotions, and possible long-term beneficial effects on personality and relationships.
Quantifying these harms and benefits is far more difficult than estimating the mortality risk, and there is little research to help us assess the types and level of risk associated with ecstasy use beyond the general mortality rate. With almost half a million people using ecstasy over a one-year period in England & Wales, and over a million using illicit drugs other than cannabis, this is a major drawback with our prohibition-based public health strategy toward users of ecstasy and illicit drugs in general.
Dr Russell Newcombe is . Tweets @TheNewImpostor