Young adult ecstasy users' enhancement of the effects of their ecstasy use.
Abstract: This study examines drug effect-enhancing behaviors practiced by young adult users of the drug, Ecstasy. Between August 2002 and August 2004, 283 face-to-face interviews were conducted with active Ecstasy users. Study participants were recruited in the Atlanta, Georgia metropolitan area using a targeted sampling approach. The large majority of study participants (87%) engaged in at least one behavior specifically designed to bolster the effects of their Ecstasy use, with 61% of the study participants reporting having engaged in at least three such behaviors during the past 30 days. Taking steps to boost one's Ecstasy-related high was associated with binging on Ecstasy and a variety of adverse outcomes, such as experiencing a greater number of negative consequences resulting from Ecstasy use and experiencing more Ecstasy-related drug dependency symptoms. Multivariate analysis revealed several factors associated with greater involvement in effects-boosting behaviors, including race (not being African American), spending time with other drug users, using Ecstasy for its touch-enhancing qualities, enjoyment of the music-and-Ecstasy-use experience, and childhood maltreatment experiences. The implications of these findings for treatment, prevention, and intervention for drug problems among Ecstasy users are discussed.

Keywords--Ecstasy use, enhancing drug effects, MDMA, young adults
Article Type: Report
Subject: Ecstasy (Drug) (Complications and side effects)
Ecstasy (Drug) (Research)
Drug abuse (Care and treatment)
Drug abuse (Prevention)
Drug abuse (Complications and side effects)
Drug abuse (Research)
Authors: Klein, Hugh
Elifson, Kirk W.
Sterk, Claire E.
Pub Date: 06/01/2009
Publication: Name: Journal of Psychoactive Drugs Publisher: Haight-Ashbury Publications Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2009 Haight-Ashbury Publications ISSN: 0279-1072
Issue: Date: June, 2009 Source Volume: 41 Source Issue: 2
Topic: Event Code: 310 Science & research
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 208534960
Full Text: Simultaneously using multiple drug types as a means of enhancing the effects of a drug-related high and/or to soften the effects of coming down from a drug-related high are common occurrences (see, for example, Booth et al. & 2006; Feilgelman, Gorman & Lee 1998; Peters et al. 2007; SAMHSA 2005). Polydrug use appears to exist without regard to the user's drug of choice and has been reported among primary users of crack (Peters et al. 2007), methamphetamine (Booth et al. 2006), heroin (Backmund et al. 2005; Kaufman, Chitwood, Comerford, & Koo, 2004), and cocaine (Booth et al. 2006; Coffin et al. 2003). Among Ecstasy users, few report using no other drugs and polydrug use appears to be especially common (Boeri et al. In press; Copeland, Dillon & Gascoigne 2006; Hopper et al. 2006; Wish et al. 2006; Martins, Mazzotti & Chilcoat 2005; Schensul, Convey & Burkholder 2005; Hansen, Maycock & Lower 2001). This is of concern because polydrug use has been linked to an elevated risk for drug-related problems and experiencing adverse consequences in various aspects of users' lives (Midanik, Tam & Weisner 2007; Feilgelman, Gorman & Lee 1998).

Although many drug users use a variety of drugs in combination with one another in an effort to boost the effects of their drug-related highs, little has been written about other behaviors in which drug users may engage to achieve a similar goal. This absence of information is particularly noteworthy in the case of the drug Ecstasy (a.k.a., MDMA), because users of this specific drug may be more likely than users of other drug types to engage in effects-enhancing practices. Among adolescent and young adult Ecstasy users, use of the drug often is associated with "raves," which are music/dance clubs that have been oriented toward camaraderie, physical closeness with others, and the enhancement of all of the senses (Bahora, Sterk & Elifson In press; Boeri, Sterk & Elifson 2004; Parrott 2002; Sloan 2000; Diemel & Blanken 1999). Toward this end, many Ecstasy users employ a variety of strategies to enhance the high. For instance, glow sticks are being used to increase the visual psychedelic effects of Ecstasy use (Morrissey 2008). As another example, surgical and other types of facial covering masks are used along with inhaled vapor rubs (e.g., Vick's Vaporub) to heighten the euphoric effects of Ecstasy intake (Morrissey 2008). This is done because many Ecstasy users report feeling more intense drug effects as a result of the combination of scents/fumes from the vapor rubs and Ecstasy use. As a third example, some MDMA users like to be rubbed with lotions or soft-textured objects because tactile contact with these products while high on Ecstasy enhances the drug's effects (Porrata 2008). Current knowledge of the extent to which Ecstasy users engage in these high-enhancing behaviors is limited. Consequently, there is limited research on the problems that may arise from engaging in these high-enhancing behaviors, or the factors that are associated with Ecstasy users' greater/ lesser involvement in practicing high-enhancing behaviors. This study examines these issues in a community-recruited sample of young adult Ecstasy users.

METHODS

Procedures

The data presented in this article are part of a cross-sectional study, Project X, on Ecstasy use. The principal goals of this study were to examine life issues and challenges, substance use and abuse, psychological and psychosocial functioning, and a variety of HIV-related risk behaviors among young adult Ecstasy users. Between August 2002 and August 2004, 283 young adults who actively used Ecstasy were interviewed in Atlanta, Georgia.

To be eligible for participation in Project X, study participants had to be between 18 and 25 years of age and they had to be active Ecstasy users, which was defined as having used Ecstasy on at least three different days during the 90 days prior to their interview. Exclusion criteria included being in drug treatment or any other institutional setting, being unable to conduct the interview in English, and being intoxicated at the time of the interview.

The initial recruitment was based on information from the present authors' previous research, information obtained from other local drug researchers, and information from local social and health service providers. Using ethnographic mapping, we identified additional locations for recruitment (Boeri, Sterk & Elifson 2004). Targeted sampling (Watters & Biernacki 1989) was used to identify public and private locations from which to recruit potential study participants. Passive recruitment, involving the posting of flyers in local music venues and areas with greater concentrations of young adults, was also utilized. Individuals who called the project phone line listed on the flyers were screened over the phone using the same short form that recruiters presented. A team of ethnographers and interviewers, including five females (three Caucasian, one African American, and one Asian American) and three males (two African American and one Latino), conducted the recruitment and interviewing.

Once a potential respondent was identified as meeting the eligibility criteria, interviews were scheduled with interested individuals. The interviews were held at mutually agreed-upon central locations and included such venues as the project offices, the participant's home, a local restaurant or cafeteria, coffee shops, community centers, and the interviewer's car. The informed consent procedures (which had been approved by both Georgia State University's and Emory University's Institutional Review Boards) were reviewed and signed prior to the collection of any data. On average, the face-to-face interviews lasted 90 minutes. They were conducted using a computer-assisted interview (i.e., CASI). Study participants received $25 compensation for their time.

Measures

Data were collected using an instrument developed specifically for this study, based on formative research among Ecstasy users. Some items used in the assessment were derived from instruments that have been shown to produce both valid and reliable results from drug users. These include items from the Risk Behavior Assessment as developed by the National Institute on Drug Abuse (Needle et al. 1995), the Addiction Severity Index (McLellan et al. 1985), and the Global Appraisal of Individual Needs (Dennis et al. 1995).

The main variables of interest in these analyses are "drug use and drug-related problems" and "Ecstasy high-enhancing behaviors." Drug use and drug-related problems were measured with several items: (1) the extent to which study participants reported experiencing positive effects as a result of their Ecstasy use (continuous scale measure comprised of nine items, Cronbach's alpha = 0.80), (2) the extent to which respondents reported experiencing negative effects as a result of their Ecstasy use (continuous scale measure comprised of 15 items, Cronbach's alpha = 0.73), (3) the number of negative effects experienced during the past 30 days as a result of "coming down from" Ecstasy (continuous scale measure comprised of six items, Cronbach's alpha = 0.65), (4) ever having binged on Ecstasy (yes/no), (5) the number of drug dependency symptoms experienced as a result of Ecstasy use (continuous scale measure comprised of seven items, Cronbach's alpha = 0.63), and (6) the number of different drug types used during the past 30 days (continuous measure).

Ecstasy high-enhancing behaviors were measured using a nine-item scale (Cronbach's alpha = 0.78), with higher scores indicating the taking of more steps to enhance the effects of one's Ecstasy use. The scale's items include the use of masks (to heighten drug effects), glow sticks (to heighten the visual sensory experience), fans (for their cooling and visual sensory effects), soft-textured objects (to enhance the drug's physical sensations), pacifiers, chewing gum, and lollipops (for the prevention of teeth clenching and for the heightening of taste sensations), orange juice (for the prevention of dehydration and for the heightening of taste sensations), and vapor rubs or vapor inhalers (to heighten the olfactory sensory experience).

In the second part of the analysis, in which the focus is on identifying variables that are associated with greater/ lesser involvement in people's Ecstasy-enhancement efforts, several types of predictor variables were considered. Demographic characteristics included in these analyses were gender (male versus female), age (continuous measure), race/ethnicity (dichotomous measure comparing Caucasians to non-Caucasians), marital status (dichotomous measure comparing "involved" versus other than "involved" persons), and sexual orientation (coded as heterosexual versus other than heterosexual).

Several substance use/abuse items were also used in these analyses, including a number of items specific to the Ecstasy use experience. These measures were: using Ecstasy for its touch-enhancing properties (continuous scale measure, Cronbach's alpha = 0.80), enjoying the combination of lights/lighting and Ecstasy use (continuous scale measure, Cronbach's alpha = 0.81), enjoying the combination of music and Ecstasy use (continuous scale measure, Cronbach's alpha = 0.75), age of first alcohol use (continuous measure), age of first alcohol intoxication (continuous measure), number of alcohol-related problems experienced during past 30 days (continuous scale measure, Cronbach's alpha = 0.83), and age of first illegal drug use (continuous measure). Finally, a few items were used to assess childhood/adolescent experiences with neglect, and childhood/adolescent and past-year experiences with emotional abuse, physical abuse, and sexual abuse. These items were taken from Bernstein and Fink's (1998) Childhood Trauma Questionnaire.

Analysis

The first part of the analysis was undertaken to assess whether or not taking steps to enhance one's Ecstasy high was related to a variety of drug use/abuse measures. The independent variable was a continuous measure, and five of the six dependent variables were also continuous measures. For these particular analyses, simple regression was used. For the other variable (i.e., whether or not the person had ever binged on Ecstasy), the dichotomous nature of the outcome measure resulted in the choice of logistic regression as the analytical tool.

The second part of the analysis, which was designed to identify the factors that were predictive of the extent to which study participants engaged in high-enhancing activities after using Ecstasy, was undertaken in two steps. Initially, separate bivariate analyses were conducted to determine whether taking effects-enhancing steps (now used as the dependent variable) was related to the various independent variables under consideration (e.g., race, gender, drug use factors, childhood maltreatment experiences, etc.). For testing the bivariate relationships, whenever the predictor variable was dichotomous (e.g., gender), Student's t tests were used. Whenever the independent variable was continuous in nature (e.g., age of first drug use, extent of childhood maltreatment experienced), simple regression was used. Analytically, the next step was for items to be entered into a multivariate model. Both forward selection and backward elimination approaches were used, to make sure that the order of entry or removal from the equation did not affect the outcome of the analysis. Only statistically significant contributors were retained in the final equation. Throughout these analyses, results are reported as statistically significant whenever p < .05.

RESULTS

Almost all study participants (87.3%) reported engaging in at least one of the nine possible Ecstasy-related high-enhancing behaviors studied, with the majority reporting engaging in at least three of these (61.5%). The mean number of Ecstasy-enhancing behaviors reported was 3.6 (SD = 2.6, range = 0-9). Among the most common of these behaviors were the use of vapor rub or vapor inhalers (50.9%), glow sticks (48.8%), fans (35.3%), soft-textured objects (33.6%), and the use of facial masks (17.3%) to enhance the user's full sensory experience during the Ecstasy use episode.

As Table 1 shows, there were a number of ways in which enhancing Ecstasy's effects corresponded to people's overall drug-use behaviors. The more behaviors in which people engaged to bolster their Ecstasy high, the greater the number of adverse effects they reported experiencing as a result of their use (F = 41.92, p < .0001). Similarly, the more effects-enhancing behaviors in which Ecstasy users engaged, the greater their number of Ecstasy-related drug dependency symptoms (F = 9.49, p = .0023). Moreover, the greater the number of effects-enhancing behaviors, the greater their total number of different drugs used (F = 55.05, p < .0001). Also, there was a direct relationship between the extent to which people tried to enhance the effects of their Ecstasy use and their likelihood of having binged on Ecstasy at some point in their lives (OR = 1.25, C[I.sub.95] = 1.13-1.38, p < .0001). In contrast to the preceding, enhancing one's Ecstasy high was not found to be related to the number of positive Ecstasy use-related effects that people reported or to the number of negative effects they reported experiencing as a result of "coming down" from an Ecstasy high.

Having established a link between taking steps to enhance an Ecstasy high and substance use/abuse-related measures, the next step in the analysis was to identify the factors associated with enhancing one's Ecstasy high. Two of the demographic variables examined were found to be related to boosting one's drug-related high: age and race. The younger study participants were, the more they tended to do to try to bolster the effects of their Ecstasy use (F = 7.73, p = .0058). African Americans engaged in less than half the number of Ecstasy-boosting behaviors as their non-Black counterparts did (1.9 versus 4.6, t = 10.10, p < .0001).

Several of the drug-related measures studied were found to be associated with the extent to which people took steps to enhance their Ecstasy-related high. People who lived with other drug users engaged in approximately 25% more Ecstasy effect-enhancing behaviors than those who did not live with substance abusers (3.8 versus 3.0, t = 2.28, p = .0234). Persons who "hung out with" drug abusers reported engaging in nearly triple the number of effect-boosting activities compared to their peers who did not spend time with drug abusers (3.7 versus 1.3, t = 2.95, p = .0035). The younger people were when they had their first drink of alcohol (F = 4.21, p = .0411), the younger they were when they first became intoxicated as a result of drinking (F = 4.71, p = .0308), and the more alcohol-related problems they had experienced recently (F = 4.53, p = .0341), the more things they reported doing to boost their Ecstasy-related high.

Similarly, several of the Ecstasy-specific items were related to the extent to which people took steps to enhance the effects of their Ecstasy use. For example, the more that people reported using music in conjunction with their Ecstasy use (F = 25.05, p < .0001) or the more that they liked to use lights and lighting in conjunction with their Ecstasy use (F = 28.53, p < .0001) or the more that they used Ecstasy for its touch-related qualities and sensations (F = 20.04, p < .0001), the more things they tended to do to buttress the effects of the drug. As a final example, the greater the level of risk that people perceived to result from Ecstasy use, the more they tended to take steps to enhance their Ecstasy high (F = 6.09, p = .0142).

In addition to the preceding, several of the childhood maltreatment measures were also linked to boosting one's Ecstasy high. Included among these were the amount of emotional abuse experienced during one's formative years (F = 4.84, p = .0287), the amount of emotional abuse endured during the past year (F = 4.77, p = .0299), and the extent to which one had been neglected or abused sexually, physically, and emotionally during one's childhood and adolescence (F = 5.60, p = .0186). For all of these measures, maltreatment was associated with engaging in a larger number of high-enhancing behaviors.

The final step in the analysis was to enter the preceding items into a multivariate equation, to determine which ones contributed significantly and uniquely to the prediction of the extent to which people took steps to enhance their Ecstasy high. In all, as Table 2 shows, five such variables were identified. They were: race (not being African American), spending time with drug abusers, enjoyment of the combination of Ecstasy and music, using Ecstasy for its touch-enhancing qualities, and the extent to which people had been maltreated during their formative years. Together, these items explained 38.1% of the total variance.

DISCUSSION

Before discussing our main conclusions, we would like to acknowledge three potential limitations of this research. First, the data collected as part of this study of young adult Ecstasy users were all based on uncorroborated self-reports. Therefore, the extent to which respondents underreported or overreported their involvement in risky behaviors is unknown. In all likelihood, the self-reported data can be trusted, as numerous authors have noted that persons in their research studies (which, like the present study, have included fairly large numbers of substance abusers) have provided accurate information about their behaviors (Yacoubian & Wish 2006; Jackson et al. 2004; Higgins et al. 1995; Anglin, Hser & Chou 1993).

A second possible limitation pertains to recall bias. Respondents were asked to report about their beliefs, attitudes, and behaviors during the past 30 days, the past 90 days, and the past year, depending upon the measure in question. These time frames were chosen specifically (1) to incorporate a large enough amount of time in the risk behavior questions' time frames so as to facilitate meaningful variability from person to person, and (2) to minimize recall bias. The exact extent to which recall bias affected the data cannot be assessed, although other researchers collecting data similar to that captured in this study have reported that recall bias is sufficiently minimal that its impact upon study findings is likely to be small (Jaccard & Wan 1995).

A third possible limitation of these data comes from the sampling strategy used. All interviews were conducted in the Atlanta, Georgia metropolitan area. There may very well be local or regional influences or subcultural differences between these persons and those residing elsewhere that could affect the generalizability of the data. Additionally, the chain referral sampling approach used to identify study participants is not a random sampling strategy, and there may be inherent biases involved in using this method of choosing participants. A good discussion of these issues may be found in Heckathorn (1997), along with strategies that can be employed to minimize any bias that could result from the use of a chain-referral sampling approach.

Despite these possible--and, we contend, minimal--limitations, we believe that many interesting and important findings came about in the present study. First, the study results showed that nearly all of the young adult Ecstasy users participating in this research took specific steps other than polydrug use as part of their drug-use rituals/practices to boost the effects of their Ecstasy use. Indeed, the majority of them engaged in at least three such effects-enhancing behaviors. The most common of these behaviors were the use of vapor rub or vapor inhalers, glow sticks, fans, and/or soft-textured objects to maximize the sensory effects of Ecstasy use. Although simultaneously using other drugs in combination with one's drug of choice is a common occurrence among users of illegal drugs wishing to bolster their drug-related "highs" (Falck et al. 2005; Kurtz et al. 2005), engaging in these sensory-enhancing practices is not a common behavior among users of most drug types. The use of vapor inhalers or glow sticks or soft objects in itself is not problematic. When it comes to providing drug treatment to Ecstasy users, however, involvement in these practices is likely to be of greater concern because, as part of Ecstasy users' drug-use rituals, they also become part of the behavioral repertoires that must be addressed and "undone" or "unlearned" if treatment is to be successful. Basically, the more complicated or the more highly ritualized the drug-use process is for people, the more difficult it tends to be to treat their drug problems. Thus, our findings suggest that among young adult Ecstasy users, special attention may need to be paid to those who engage in a variety of effects-enhancing practices.

This is all the more true when one considers our findings pertaining to the relationship of taking steps to bolster one's Ecstasy use effects and actual drug (ab)use behaviors. In this regard, we found that the more behaviors in which people engaged to increase the effects of their Ecstasy use, the more likely they were to have experienced negative effects as a result of their Ecstasy use, the more drug dependency symptoms they were likely to have experienced as a result of their Ecstasy use, and the greater the likelihood was that they had binged on Ecstasy at least once before. These findings indicate that the young adults who engage in the greatest number of effects-enhancing behaviors vis-a-vis their Ecstasy use are the ones who are experiencing the greatest number of adverse consequences as a result of their Ecstasy use as well. In addition to the obvious drug treatment-related implication here, there may also be a prevention-related and/or an intervention-related implication inherent in this finding: depending upon exactly when in a person's Ecstasy use history the effects-bolstering behaviors begin, the onset of such behaviors may signal a growing involvement and a developing problem with the use of that drug. If this is the case, then it indicates that prevention and intervention workers in the drug abuse field might be able to minimize harms resulting from Ecstasy use by targeting users who are beginning to involve themselves in behaviors such as using vapor inhalers, glow sticks, and the like in conjunction with their Ecstasy use. Learning more about the factors that lead to the onset of these effects-enhancing behaviors and about the temporal relationship of this onset to the initiation of problematic Ecstasy use would be fruitful avenues for future research.

Our findings pertaining to the predictors of greater/lesser involvement in Ecstasy-related effects-enhancing behaviors identified several factors worthy of note and brief discussion. First, we found that, compared to members of other racial groups, African Americans engaged in significantly fewer Ecstasy-boosting behaviors. This may be the result, at least in part, of the relative newness of the drug in the African-American community and the fact that Ecstasy has not become entrenched among African-American young adults to the extent that it has among their Caucasian counterparts (Ompad et al. 2005; Schensul et al. 2005). It is also possible that there are normative and cultural differences in the social settings in which African Americans and members of other racial/ethnic groups use Ecstasy. Relatively little has been published specifically on the subject of racial differences in Ecstasy use, leading some researchers to comment that there is a need--perhaps a greater need than ever before, with the recent proliferation of the drug into minority communities--to study Ecstasy use in minority populations (Novoa et al. 2005; Ompad et al. 2005). We concur with this recommendation.

The present research also revealed that spending a greater amount of one's personal time with substance abusers was associated with more involvement in Ecstasy-related effects-enhancing behaviors. It seems likely to us that at least some the drug (ab)users with whom the young adult Ecstasy users in this study spent their leisure time were more experienced drug (ab)users than the study participants themselves and, therefore, may have been the persons responsible for introducing them to the effects-enhancing practices in question. This highlights the importance of changing drug abusers' social networks and the way that people spend their social/leisure time if they wish to recover from drug abuse. Other researchers have noted the importance of doing this (Edelen et al. 2007; Bond, Kaskutas & Weisner 2003; Booth et al. 1998).

Our multivariate analysis also showed that two specific properties of the Ecstasy use experience were associated with greater involvement in effects-enhancing behaviors: using Ecstasy for its touch-enhancing qualities and enjoying the combined music-and-Ecstasy-use experience. Taken together, these particular findings suggest that the persons who do the most things to enhance the effects of their Ecstasy use are the same ones who also enjoy other sensory aspects (e.g., music, sensual touch) of the Ecstasy use experience. Although numerous authors have written about users' various subjective experiences using Ecstasy (see Baylen & Rosenberg 2006), little has been written in the scientific literature about the role that such factors as music and sensual touch play in Ecstasy use or in Ecstasy use-related problems. Some information about this subject may be found in Theall, Elifson, and Sterk's (2006) analysis of the role that sensual touch plays in young adult Ecstasy users' HIV risk practices, as well as in De Almeida & Silva's (2005) study of Ecstasy users in Brazil. Overall, however, additional research is needed in order to understand more fully the relationship of effects-enhancing behaviors among Ecstasy users and the broader role played by the Ecstasy use sensory experiences from music and sensual touch.

Finally, we would like to address the last of our multivariate findings--namely, the direct association between the amount of childhood maltreatment experienced and the number of Ecstasy-related effects-enhancing behaviors practiced. Previous studies have reported a link between childhood neglect, physical abuse, sexual abuse, and/or emotional abuse and subsequent use of the drug Ecstasy (Brennan et al. 2007; Singer et al. 2004; Swanston et al. 2003). Worthy of note, however, is the fact that these studies have reported only generally on an association between childhood maltreatment and greater Ecstasy use in adulthood, and did not address the specific finding that we obtained pertaining to childhood maltreatment and engaging in effects-boosting practices. The present study's finding expands the previous research by documenting yet one more way in which childhood maltreatment experiences lead to adverse outcomes in adulthood. It also highlights the need to consider previously-abused young adult Ecstasy users as an "at risk" group that potentially is in need of targeted intervention.

In conclusion, this community-based study of young adult Ecstasy users found that the large majority of these individuals reported engaging in practices other than polydrug use that were specifically intended to bolster the effects of their Ecstasy-related sensory experience. Moreover, most Ecstasy users who took steps to increase the effects of their Ecstasy use engaged in a variety of these behaviors. Doing this was associated with a variety of negative outcomes, including greater negative consequences resulting from using Ecstasy, ever having binged on Ecstasy, and experiencing a larger number of Ecstasy use-related drug dependency symptoms. A closer examination of the data revealed several factors that were linked with greater involvement in effects-enhancing behaviors, including not being African American, spending more of one's leisure/social time with other drug abusers, using Ecstasy for its music-enhancing and touch-enhancing qualities, and having been victimized by neglect, physical abuse, sexual abuse, or emotional abuse during childhood and/or adolescence.

REFERENCES

Anglin, M.D.; Hser, Y. & Chou, C. 1993. Reliability and validity of retrospective behavioral self-report by narcotics addicts. Evaluation Review 17: 91-103.

Backmund, M.; Meyer, K.; Henkel, C.; Soyka, M.; Reimer, J.; & Schutz, C.G. 2005. Co-consumption of benzodiazepines in heroin users, methadone-substituted, and codeine-substituted patients. Journal of Addictive Diseases 24: 17-29.

Bahora, M.; Sterk, C. & Elifson, K. In press. Understanding recreational Ecstasy use in the United States: A qualitative inquiry. International Journal of Drug Policy.

Baylen, C.A. & Rosenberg, H. 2006. A review of the acute subjective effects ofMDMA/Ecstasy. Addiction 101: 933-47.

Bernstein, D.P. & Fink, L. 1998. Childhood Trauma Questionnaire: A Retrospective Self-Report Manual. San Antonio, TX: Psychological Corporation.

Boeri, M.; Sterk, C. & Elifson, K. 2004. Rolling beyond raves: Ecstasy use outside the rave setting. Journal of Drug Issues 34: 831-60.

Boeri, M.; Sterk, C.; Bahora, M. & Elifson, K. In press. Poly-drug use among Ecstasy users: Separate, synergistic, and indiscriminate patterns. Journal of Drug Issues.

Bond, J.; Kaskutas, L.A. & Weisner, C. 2003. The persistent influence of social networks and Alcoholics Anonymous on abstinence. Journal of Studies on Alcohol 64: 579-88.

Booth, B.M.; Leukefeld, C.; Falck, R.; Wang, J. & Carlson, R. 2006. Correlates of rural methamphetamine and cocaine users: Results from a multistate community study. Journal of Studies on Alcohol 67: 493-501.

Booth, R.E.; Kwiatkowski, C.; Iguchi, M.Y.; Pinto, F. & John, D. 1998. Facilitating treatment entry among out-of-treatment injection drug users. Public Health Reports 113: 116-28.

Brennan, D.J.; Hellerstedt, W.L.; Ross, M.W. & Welles, S.L. 2007. History of childhood sexual abuse and HIV risk behaviors in homosexual and bisexual men. American Journal of Public Health 97: 1107-12.

Coffin, P.O.; Galea, S.; Ahern, J.; Leon, A.C.; Vlahov, D. & Tardiff, K. 2003. Opiates, cocaine, and alcohol combinations in accidental drug overdose deaths in New York City, 1990-98. Addiction 98: 739-47.

Copeland, J.; Dillon, P. & Gascoigne, M. 2006. Ecstasy and the concomitant use of pharmaceuticals. Addictive Behaviors 31: 367-70.

De Almeida, S.P. & Silva, M.T. 2005. Characteristics of Ecstasy users in Sao Paulo, Brazil. Substance Use and Misuse 40: 395-404.

Dennis, M.L.; Rourke, K.M.; Lucas, R.L.; Zien, C.; Clayton, K.J.; Harris, K.M.; Caddell, J.M.; Cavanaugh, B.R. & Fleischman, D. 1995. Global Appraisal of Individual Needs (GAIN): Resource Manual. Research Triangle Park, NC: Research Triangle Institute.

Diemel, S. & Blanken, P. 1999. Tracking new trends in drug use. Journal of Drug Issues 29: 529-48.

Edelen, M.O.; Tucker, J.S.; Wenzel, S.L.; Paddock, S.M.; Ebener, P.; Dahl, J. & Mandell, W. 2007. Treatment process in the therapeutic community: Associations with retention and outcomes among adolescent residential clients. Journal of Substance Abuse Treatment 32: 415-21.

Falck, R.S.; Siegal, H.A.; Wang, J.; Carlson, R.G. & Draus, P.J. 2005. Nonmedical drug use among stimulant-using adults in small towns in rural Ohio. Journal of Substance Abuse Treatment 28: 341-49.

Feilgelman, W.; Gorman, B.S. & Lee, J.A. 1998. Binge drinkers, illicit drug users, and polydrug users: An epidemiological study of American collegians. Journal of Alcohol and Drug Education 44: 47-69.

Hansen, D.; Maycock, B. & Lower, T. 2001. 'Weddings, parties, anything ...': A qualitative analysis of Ecstasy use in Perth, Western Australia. International Journal of Drug Policy 12: 181-99.

Heckathorn, D.D. 1997. Respondent-driven sampling: A new approach to the study of hidden populations. Social Problems 44: 174-99.

Higgins, S.T.; Budney, A.J.; Bickel, W.K.; Badger, G.J.; Foerg, F.E. & Ogden, D. 1995. Outpatient behavioral treatment for cocaine dependence: One-year outcome. Experimental and Clinical Psychopharmacology 3: 205-12.

Hopper, J.W.; Su, Z.; Looby, A.R.; Ryan, E.T., Penetar, D.M.; Palmer, C.M. & Lukas, S.E. 2006. Incidence and patterns of polydrug use and craving for Ecstasy in regular Ecstasy users: An ecological momentary assessment study. Drug and Alcohol Dependence 85: 221-35.

Jaccard, J. & Wan, C.K. 1995. A paradigm for studying the accuracy of self-reports of risk behavior relevant to AIDS: Empirical perspectives on stability, recall bias, and transitory influences. Journal of Applied Social Psychology 25: 1831-58.

Jackson, C.T.; Covell, N.H.; Frisman, L.K. & Essock, S.M. 2004. Validity of self-reported drug use among people with co-occurring mental health and substance use disorders. Journal of Dual Diagnosis 1: 49-63.

Kaufman, J.M.; Chitwood, D.D.; Comerford, M. & Koo, D. 2004. Characteristics and patterns of use among regular heroin sniffers. Journal of Drug Issues 34: 805-30.

Kurtz, S.P.; Inciardi, J.A.; Surratt, H.L. & Cottler, L. 2005. Prescription drug abuse among Ecstasy users in Miami. Journal of Addictive Diseases 24: 1-16.

Martins, S.; Mazzotti, G. & Chilcoat, G. 2005. Trends in Ecstasy use in the United States from 1995 to 2001: Comparison with marijuana users and association with other drug use. Experimental and Clinical Psychopharmacology 13: 244-52.

McLellan, A.T.; Luborsky, L.; Cacciola, J.; Griffith, J.; Evans, F.; Barr, H. & O'Brien, C. 1985. New data from the Addiction Severity Index: Reliability and validity in three centers. Journal of Nervous and Mental Diseases 173: 412-28.

Midanik, L.T.; Tam, T.W. & Weisner, C. 2007. Concurrent and simultaneous drug and alcohol use: Results of the 2000 National Alcohol Survey. Drug and Alcohol Dependence 90: 72-80.

Morrissey, M.R. 2008. Ecstasy Introduction. Available at: www.denverda.org/Prosecution_Units/Drug_Court/Ecstasy_Intro.htm

Needle, R.; Fisher, D.G.; Weatherby, N.; Chitwood, D.; Brown, B.; Cesari, H.; Booth, R.; Williams, M.L.; Watters, J.; Andersen, M. & Braunstein, M. 1995. Reliability of self-reported HIV risk behaviors of drug users. Psychology of Addictive Behaviors 9: 242-50.

Novoa, R.A.; Ompad, D.C.; Wu, Y.; Vlahov, D. & Galea, S. 2005. Ecstasy use and its association with sexual behaviors among drug users in New York City. Journal of Community Health 30: 331-43.

Ompad, D.C.; Galea, S.; Fuller, C.M.; Edwards, V. & Vlahov, D. 2005. Ecstasy use among Hispanic and black substance users in New York City. Substance Use and Misuse 40: 1399-1407.

Parrott, A.C. 2002. Recreational Ecstasy/MDMA, the serotonin syndrome, and serotonergic neurotoxicity. Pharmacology, Biochemistry, and Behavior 71: 837-44.

Peters, R.J. Jr.; Williams, M.; Ross, M.W.; Atkinson, J. & Yacoubian, G.S. Jr. 2007. Codeine cough syrup use among African-American crack cocaine users. Journal of Psychoactive Drugs 39: 97-102.

Porrata, T. 2008. MDMA. Available at: /www.projectghb.org/2008/ecstasy.php

Schensul, J.; Convey, M. & Burkholder, G. 2005. Challenges in measuring concurrency, agency and intentionality in polydrug research. Addictive Behaviors 30: 571-74.

Schensul, J.J.; Diamond, S.; Disch, W.; Bermudez, R. & Eiserman, J. 2005. The diffusion of Ecstasy through urban youth networks. Journal of Ethnicity and Substance Abuse 4: 39-71.

Singer, L.T.; Linarea, T.J.; Ntiri, S.; Henry, R. & Minnes, S. 2004. Psychosocial profiles of older adolescent MDMA users. Drug and Alcohol Dependence 74: 245-52.

Sloan, J. 2000. It's all the rave: Flower power meets technoculture. American Criminal Justice Society Today 29: 3-6.

Substance Abuse and Mental Health Services Administration (SAMHSA). 2005. Results from the National Survey on Drug Use and Health: National Findings. NIH Publication No. SMA 05-4062. Rockville, MD: SAMHSA.

Swanston, H.Y.; Plunkett, A.M.; O'Toole, B.I.; Shrimpton, S.; Parkinson, P.N. & Oates, R.K. 2003). Nine years after child sexual abuse. Child Abuse and Neglect 27: 967-84.

Theall, K.P.; Elifson, K.W. & Sterk, C.E. 2006. Sex, touch, and HIV risk among Ecstasy users. AIDS and Behavior 10: 169-78.

Watters, J. & Biernacki, P. 1989. Targeted sampling: Options for the study of hidden populations. Social Problems 36: 416-30.

Wish, E.D.; Fitzelle, D.B.; O'Grady, K.E.; Hsu, M.H. & Arria, A.M. 2006. Evidence for significant polydrug use among Ecstasy-using college students. Journal of American College Health 55: 99-104.

Yacoubian, G.S. Jr. & Wish, E.D. 2006. Exploring the validity of self-reported Ecstasy use among club rave attendees. Journal of Psychoactive Drugs 38: 31-34.

Hugh Klein, Ph.D. *; Kirk W. Elifson, Ph.D. ** & Claire E. Sterk, Ph.D. ***

[dagger] This research was supported by a grant from the National Institute on Drug Abuse (R01-DA014232).

* Senior Researcher, Rollins School of Public Health, Emory University, Atlanta, GA; Research Associate Professor, Prevention Sciences Research Center, Morgan State University, Baltimore, MD.

** Professor Emeritus, Rollins School of Public Health, Emory University, Atlanta, GA.

*** Professor, Rollins School of Public Health, Emory University, Atlanta, GA.

Please address correspondence and reprint requests to Hugh Klein, Ph.D., 401 Schuyler Road, Silver Spring, MD 20910; phone: 301-588-8875, fax: 301-588-8875; email: hughk@aol.com
TABLE 1
Enhancing Ecstasy's Effects and Drug Use Outcomes

                                                   Statistical
Drug Use Outcome                     b ([beta])   Significance

Recently-Experienced Positive       0.10 (0.11)      p = .0755
  Effects of Ecstasy Use

Recently-Experienced Negative       0.44 (0.36)      p < .0001
  Effects of Ecstasy Use

Ecstasy-Related Drug Dependency     0.13 (0.18)      p = .0023
  Symptoms Experienced

Number of Different Drug Types      0.32 (0.40)      p < .0001
  Used (Past 30 Days)

Recently-Experienced Negative       0.01 (0.02)      p = .7002
  Effects when Coming Down
  from Ecstasy Use

Ever Binged on Ecstasy              0.22 (0.32)      p < .0001

TABLE 2
Predictors of the Extent to Which People Did Things
to Enhance Their Ecstasy High

                                                   Statistical
Predictor Measure                    b ([beta])   Significance

Race = African American            -2.55 (0.44)      p < .0001

Hanging Out with                   1.70 (0.11)       p = .0238
Substance Abusers

Enjoying the Music-and-Ecstasy     0.10 (0.16)        p = .002
Combination

Using Ecstasy for its              0.06 (0.20)       p = .0001
Touch-Enhancing Properties

Total Amount of Childhood          0.00 (0.11)       p = .0306
Maltreatment Experienced
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