Should Ecstasy (MDMA) be legalised?
If alcohol and tobacco are legal, then a substance far less damaging both to its consumers and to wider society should arguably be legalised. Moreover doing so may cause persons with alcohol and tobacco addictions to substitute into something cheaper, more pleasant to consume, less distorting of the mind, less damaging of the body, less harmful in every respect and less addictive. Any country that permits alcohol consumption or cigarette smoking as a matter of logic and policy should consider permiting the (regulated) consumption of 'MDMA' or 'Ecstasy' (which as will be explained below is the same thing).
A public health issue for the youth of today
Drug addiction is predominantly an affliction of the youth. So it affects you, the reader, either because your own children or grandchildren will inevitably be exposed to the matters this essay discusses; or the children or grandchildren of someone dear to you will be. All young people are exposed to drugs; it is impossible to prevent it; and hence it is an issue that requires the calm and reasoned attention of us all, from the highest Lord to the lowliest pauper. We must recognise that recreational drugs exist; that they can be a problem; that they need not always be a problem but everything depends on the drug in question (alcohol and tobacco being two of the most harmful); and this is a subject about which we will almost inevitably feel old and out-of-touch if and when we actually listen to what young people have to say about it. Nevertheless we must not succumb to the temptation of taboo.
So this is an essay about the welfare and future of our youth.
Too often debates about drug use get bound together with debates about 'alternative culture', by which young people universally mean expressing their difference from their parents or those who brought them up. These issues should be kept apart. All young people express a desire to have separate values and lifestyles from those of their parents or guardians at some stage, often for a long time indeed. Drug use, including alcohol and tobacco use, by contrast is a deliberate choice (at least initially, depending on the drug), that needs to be studied through a cool and rational lens.
What is MDMA?
Before we go further let us define our terms. The narcotic we are referring to in this essay is 3,4-Methylenedioxymethamphetamine, known as 'MDMA' for short. It is not naturally occurring; it must be manufactured from some common substances. In its pure form it is a brown translucent crystal that tastes disgusting. For this reason it is infrequently sold pure but instead is incorporated into slow-release tablets, that are called 'Ecstasy'. The typical onset time of pure MDMA, eaten, is approximately 30 minutes. The typical onset time of an Ecstasy tablet is 45 minutes to one hour fifteen minutes, depending on the strength of the pill (i.e. how much MDMA is in it) and the nature of the slow-release substance it is mixed with (typically some semi-soluble compound
that will melt more quickly, as it were, in the stomach's acidic environment).
MDMA in small quantities is an anti-depressant that works on the dopamine and serotonin pathways, much like the popular selective serotonin reuptake inhibitors (SSRI's) and similar commonly prescribed psychiatric medications such as fluoxetine (Prozac), paroxetine and sertraline (Zoloft). MDMA was discovered in 1912 and was legal in most countries until 1985, so a lot is known about it from lawful scientific research prior to its general prohibition.
There is a debate underway at the time of writing as to whether SSRI inhibitors are effective psychiatric treatments for depression, one study indicating an absence of correlation between use of these medicines and an alleviation of symptoms. However the latest research is controversial in several ways and may turn out to be flawed. This debate has no relationship to the subject of our essay, MDMA, which was not part of the contested SSRI study.
In higher quantities, typical of taking an Ecstasy tablet, MDMA is a euphoric with a typical period of effect once onset commences of three to five hours. This is important, as addiction specialists realise; the fact that MDMA has a relatively long period of effect amongst recreational narcotics makes it less addictive because there is less of the desire to take more of it quickly to 'stay up', as is the case with cocaine or amphetamines for example. The desire for repeat administrations over short periods due to the short-term effects of a narcotic are one of the principal catalysts of psychological addiction. This is confirmed by any chain smoker or any person consuming alcohol who has decided, again and again, to have one more drink in a bar or at home.
One of the qualities that likely facilitates addictive qualities of MDMA, to the extent there are any such qualities (and that is wide open to debate), is, like the SSRI class of medicines, that it serves as a diet pill. It suppresses the appetite in the same way as SSRI medications typically do: by loosening the digestive tract as well as tightening the stomach (see below for a more in-depth discussion). There is no evidence that this effect, whether caused by SSRI's or by their cousin MDMA, causes long term harm. However it would be easier to test this hypothesis were MDMA legal.
Ecstasy tablets come in a variety of shapes sizes and colours. Each manufacturer of Ecstasy tablets (mostly in the Netherlands) has a different 'brand'.
In the absence of lawful testing facilities, it is impossible to say how strong the Ecstasy pill is (i.e. how much MDMA it contains) without putting it in your mouth, swallowing it and waiting for the intensity of effect.
Copious quantities of information are available on the internet purporting to classify Ecstasy tablets for strength, depending on their colour, size, and/or distinctive trademarks (some have little skills implanted on their surfaces, for example). None of this information is reliable. It is written by junkies, imagining things.
Indeed in any single batch of Ecstasy pills there may be a wide range of strengths between one tablet to another. That is because the process of mixing MDMA with the chemical substance that causes slow release, and with dye (to create each distinctive colour), is often not particularly precise.
In summer months, when demand is higher, Ecstasy tablets may be correspondingly weaker (an elementary principle of supply / demand economics given fixed prices which are common in the sale of MDMA and Ecstasy).
Some sources raise alarms about 'fake Ecstasy', that is to say tablets masquerading as Ecstasy but using another narcotic as the principal stimulant instead of MDMA. Although such things do occasionally transpire, they are rare because any other narcotic is probably more expensive to make than simple Ecstasy tablets, and hence there is no financial incentive to produce 'enhanced Ecstasy' (as we might call it).
MDMA / Ecstasy does not cause hallucinations or psychosis. At most it causes a dizzy head and silliness. On an inexperienced user of an emotionally sensitive disposition it may cause anxiety as the person worries about the effects. In an unfit or obese person the narcotic may cause fatigue because it induces a desire for physical exercise. (Whether or not a person is fit and healthy enough to endure such exercise without discomfort is another matter altogether.)
If you consume something you consider to be an Ecstasy tablet that causes you hallucinations or psychosis (e.g. paranoia or thinking that things are not as they really are), you have likely been taking some other drug such as psilocybin or LSD. If this happens to you, obviously warn other users that your source is not providing pure MDMA. Hallucinogens such as psiloycybin and LSD are significantly more dangerous to your mental health than MDMA, in our opinion.
Effects and side-effects of MDMA
Here are some effects of MDMA upon the mind and body:
A feeling of happiness, self-confidence, lack of inhibition and other indicators of psychiatric well-being the consumption of SSRI's is intended to induce but does not always succeed in. One way of looking at MDMA is that it is the most strikingly effective member of that class of pharmaceuticals.
Relaxation and lack of stress. In other words, MDMA serves as an anxiolyic, without the physical addictiveness of benzodiazepenes. There is no evidence that MDMA is physically addictive.
Energy for physical exercise (similar to the SSRI's but with a typical recreational dose of MDMA more intense).
The evaporation of aggression.
When it ceases to have effect, a pleasant sensation of sleepiness that is typically followed by sleep.
Where excessive amounts are consumed, there can be a loss of coordination skills. Also when excessive amounts are consumed, there can also be a sense of depression the next day, after sleep.
As to sex, something young people are in the habit of doing without their parents' or guardians' knowledge or consent, MDMA, like alcohol, may provoke the desire but takes away the performance. A lot of people 'coming down' off MDMA are too tired to have sex.
The assertion that the body overheats as a result of taking MDMA is false; the drug has no effect upon one's body temperature. If one is exercising while taking MDMA, then the body will have the usual range of reactions to heightened activity, including increased respiration, sweating and similar. Like any person engaged in vigorous exercise, care must be taken to self-rehydrate, ideally using isotonics, at regular intervals.
MDMA is not shown to cause even mid-term psychological addiction amongst its users. If a user takes MDMA over several consecutive days (think: parties in Ibiza) they return to normal within 24 hours of their final dose (plus a healthy amount of sleep).
Nor does MDMA cause any known physically addictive properties, or organ or skin tissue damage of any known kind. It can cause short-term diarrhoea by way of irritating the intestines; there are very few known cases where this effect has not entirely subsided within 24-36 hours of last use.
Anecodtally, there are very few known cases of MDMA being used daily over an extended period. The more one takes, the less effective it becomes and hence daily addiction does not seem to arise.
In terms of both psychological and physical addiction, MDMA would appear to score more highly (i.e. cause much less addiction) than the regular SSRI anti-depressants prescribed every day by psychiatrists and other doctors across the globe. Those medications are habitual in that if you do not take them every day you soon feel renewed psychiatric symptoms of depression, anxiety and the like; and they can be physically addictive in that sudden withdrawal can cause weight gain, over-eating and a lack of interest in physical exercise. If it is legitimate for SSRI inhibitors to be prescribed by doctors in certain circumstances, then should we not ask whether it must be legitimate for the same in respect of MDMA, a pharmaceutical substance that has been around for far longer than the traditional SSRI's and without obviously having any of the same dependency and withdrawal effects.
Because MDMA is (substantially) cheaper than alcohol (see below), it is hard to run the argument that occasional use of MDMA will cause narcotic-related impoverishment.
Taking MDMA does not carry with it a significant risk of death or long-term injury, even with overdose. A handful of people die each year across Europe while on Ecstasy, typically of causes aggravated by their intoxication (e.g. driving). This is statistically insignificant compared to the tens of thousands of people a year who die while intoxicated on alcohol within the same population set.
You can overdose on MDMA. You feel sick. You wait, maximum for a couple of hours, until the feeling of nausea subsides. There are no further side effects. It is unpleasant but not nearly as unpleasant as vomiting from the effects of alcohol.
The effects of MDMA upon the digestive aystem
MDMA is a laxative. It relaxes the muscles in the digestive system and can thereby cause diarrhoea, including the passage of water per rectum: similar to mild and temporary cholera. Users of MDMA may experience diarrhoea, but not too seriously. The digestive system returns to normal within 12-24 hours of last consumption.
The diarrhoea effect should cause the user to want to eat beyond their normal appetite, as food is passed through the digestive tract without being fully processed for nutritional content. This is why some people refer to MDMA as a 'diet pill'.
MDMA also encourages the urge to urinate, as it sensitises the bladder that more readily sends out a neural message making the user feel as though they want to go to the toilet.
The desire to use the toilet is often the body getting confused; it is common to feel the urge to go to the toilet only for the bladder to turn out to be empty. Observing people taking a long time to urinate in a toilet or urinal (or not being able to urinate at all) is a strong indicator of MDMA usage.
Nevertheless care should be taken to keep hydrated with istonic drinks due to excessive exit of water per rectum.
Some slow-release compounds used in the formation of Ecstasy tablets can irritate the gut; others do not have this effect. This effect causes an excessive creation of bile, causing one's stools (or diarrhoea) to emerge green. The anus will sting with moderate to severe intensity while excreting bile. Although alarming when it occurs, this is in fact harmless (as long as you eat well and consume isotonic drinks), and stools will return to their normal colour within 24-36 hours of last use.
No known studies have attempted to correlate long-term use of MDMA with effects (positive or negative) on the digestive system, although we welcome research in this area.
Alleged neurotoxicity of MDMA
A number of authors of addiction textbooks make assertions such as the following:
Ecstasy has a selective neurotoxic effect on serotonergic axons. This means that ecstasy primarily damages the nerve cells that have serotonin as a messenger substance - namely at the nerve endings called axons. Axons make particularly many contact points with other nerve cells. Damage prevents communication with other nerve cells.
This primarily affects cognitive functions such as the storage of new information in the long-term memory.
The use of ecstasy also appears to result in a disturbance of the serotonergic system.
The activity of the nerve cells, in which serotonin is the messenger substance, would decrease with ageing anyway, which is associated with dementia. There is also an advance or intensification of normal ageing processes. For example, dementia diseases can occur earlier.
These observations give rise to the following questions:
How have the neurotoxicologists drawing these conclusions arrived at them, given that neurotoxicology in its current sophisticated form is a relatively new discipline and MDMA has been banned globally from sale since 1985?
Are these mere hypotheses, and if so drawn from what chain of reasoning, and how can we test the hypotheses?
Is there any empirical evidence showing actual decrease in mental function caused by or associated with MDMA consumption?
Are these effects, if causally related to the consumption of MDMA, permanent or just temporary and reversible when a user of MDMA ceases its use?
Given that MDMA operates substantially in cross-substitution of alcohol in the 18-25 age group, what if any are the neurotoxicological effects of alcohol consumption? If there are such effects, they must be accounted for in the cost / benefit analysis of cross-substitution from other narcotics.
It would obviously be much easier to investigate these issues were MDMA legal.
In response to these queries we received the following reply from one of the very few specialists in the alleged neurotoxic effects of MDMA:
You are right, there are many more assumptions than clear facts ... my information comes from the following sources:
Andresen B, Thomasius R, Anders L, Moritz S, Petersen K, Luck S: Neuropsychological results. In: Thomasius R, eds: Ecstasy - Eine Studie zu gesundheitlichen und psychosozialen Folgen des Missbrauchs. Stuttgart: Wissenschaftliche Verlagsgesellschaft mbH 2000; 171-187.
2) Bolla KI, McCann UD, Ricaurte GA: Memory impairment in abstinent MDMA ("ecstasy") users. Neurology 1998; 51: 1532-1537.
3) Dafters RI, Duffy F, O'Donnell PJ, Bouquet C: Level of use of 3,4-methylenedioxymethamphetamine (MDMA or Ecstasy) in humans correlates with EEG power and coherence. Psychopharmacology 1999; 1456: 82-90.
McCann UD, Mertl M, Eligulashvili V, Ricaurte GA: Cognitive performance in 3,4-methylenedioxymethamphetamine (MDMA, "ecstasy") users: a controlled study. Psychopharmacology 1999; 143: 417-425.
In an experiment with rats and the administration of ecstasy in a subsequent study, there was a decrease in serotonin, 5-HIAA and tryptophan hydroxylase in the rat brain:
Pletscher A, Bartholini G, Bruderer H, Burkard WP, Gey KF: Chlorinated arylalkylamines affecting the cerebral metabolism of 5-hydroxytryptamine. J Pharmacol Exp Ther 1964; 145: 344.
Because of the disturbance of the serotonergic system, it is assumed that it can also impair the ageing process and can also be a cause of dementia.
But it has still not been confirmed. And the studies are old.
I ... consider alcohol to be the most destructive drug of all. But it is also difficult to compare ecstasy with it [based on the current state of research].
In conclusion, the question of possible neurotoxicity of MDMA is a vexed question, particularly compared with that of other narcotics from which it may serve as a cross-substitute.
Use of MDMA as a medical treatment for post traumatic stress disorder (PTSD) and other similar psychiatric illnesses
A substantial quantity of research is currently underway as to whether MDMA may be used to treat PTSD or depression. The initial indicators are positive, particularly for persistent PTSD that is not suceptible to other forms of treatment. However the research is far from conclusive and far from as analytically rigorous as we like, simply deriving from the fact that MDMA is illegal in every country in the world and cannot even be prescribed by a doctor. Testing conditions are therefore far from ideal, because test candidates (psychiatric patients) will generally be consuming MDMA for imagined medicinal purposes illicitly and therefore in circumstances into which it is hard to inject the requisite level of scientific exactitude.
Anecodtally evidence about use of MDMA to treat persistent PTSD is very positive; but it is only anecdotal.
A conference called ICPR 2022, 'Interdisciplinary Conference on Psychedelic Research', describing itself as 'Europe's leading conference on psychedelics and psychotherapy', 22-24 September 2022, Haarlem, the Netherlands, has talks presented by Matthew Baggott and Parker Singleton describing the current state of academic research on the use of MDMA as a psychiatric medicine.
Matthew Baggott is a scholar at the University of Chicago who has written extensively about the positive medicinal effects of MDMA. See here:
Parker Singleton is a scholar at Cornell University who has also written extensively about the positive medicinal effects of MDMA. See here:
We hope shortly to be able to provide links to their presentations at the 22-24 September 2022 conference, so that the reader may review the status of the evidence for him or herself.
Anecdotal observation of persons under the influence of MDMA suggests that in small (non-recreational) doses it may serve as a truth serum: the person having consumed the psychoactive substance is unable to lie, and is inclined to answer questions truthfully or genuinely to state what is on their mind upon prompting.
However at higher (recreational) doses this effect is lost, as the consumer starts to create bizarre fantasies that they speak about. These are almost always accompanied by incoherence. (e.g. 'I am going out to dance under the bright green sun today.') It is usually obvious to an experienced observer when MDMA consumption crosses the line from truth serum to elatory narcotic that causes incoherence; but there are few such observers (as the consumption of MDMA is more often than not a collective process).
The quantity of MDMA adequately to serve as a truth serum is very finely balanced and depends upon body weight, gender, habituation to MDMA (have they taken it before? How long ago?), physical and mental health more generally and probably a range of other factors unknown. However a single small crystal might be a typical guiding factor. Recall a likely 30-minute onset.
The effects are similar to sodium thiopental, scopolamine hydrobromide and midazolam / flunitrazepam (the latter two being anxiolytics of the benzodiazepene class), but without the side effects of risks of overdose associated with those medicines. MDMA is much safer than any of the above, and may be a better and more reliable truth serum in the correct doses.
Use of MDMA for this purpose is a serious crime in virtually every jurisdiction and we do not recommend it.
Effects and side-effects of alcohol
Contrast now the effects of alcohol consumption on the human mind and body:
Loss of inhibition.
Increased aggression and risks of violence.
Irrational and paranoid behaviour.
Calorific consumption and weight gain.
Repeat consumption over a given period of intoxication ('just one more'), increasing the risks of the negative consequences of drinking alcohol as ever more is consumed.
Liver damage in excess and/or over the long term.
In overdose, reverse peristalsis and physical collapse.
Unconsciousness or even death in large quantities.
Prompt loss of physical coordination.
A bad smell about the person (they 'reek of drink').
Feelings of a severe headache and physical listlessness the next day (a ',hangover').
Physical addictiveness (if a regular consumer of alcohol goes for a day or two without a drink they may experience physical symptoms of withdrawal such as shaking, as well as psychological withdrawal effects such as anxiety, depression or aggression).
Loss of money (drinking a lot of alcohol is very expensive).
High blood pressure and a reddening of the face, reducing a person's mortality.
An unhealthy lifestyle because drinking alcohol deters a person from physical exercise and, because it creates artificial feelings of hunger, often leads to overeating. These factors may cause a variety of other health problems deriving from obesity and lack of exercise. By reason of the impulse to overeat, alcoholics may not achieve a balanced diet which may cause other nutritional and health complications.
Effects and side-effects of tobacco smoking
Now consider the effects and side effects of smoking tobacco (other forms of consuming tobacco are even worse):
Tobacco smoking serves as an extreme short-,term anxiolyic (something that calms a nervous person down).
Because it is so short-term, it may cause extreme and rapid addiction to the nicotine in tobacco.
Progressive degradation of lung capacity as the tar in tobacco damages and eventually kills healthy lung tissue.
Physical and psychological addiction; absent tobacco a smoker may become irritable, edgy, paranoid and disagreeable.
Other forms of cancer.
Severe loss of money due to the need to fund the habit.
A bad smell about the person, akin to tobacco ash.
Skin damsge, including drying out of skin.
Substantial decrease in mortality due principally to the chances of contracting cancer or other smoking related diseases.
Insomnia, anxiety, other psychiatric disorders of a similar nature, and unnatural weight gain, upon withdrawal.
It is no good pretending that smoking tobacco does not have an effect upon an individual's psychology; it does. It is a recreational narcotic, and the reason people consume recreational narcotics is because they make themselves feel better. In each case there is a more or less severe psychological and/or physical downside; for both alcohol and tobacco these downsides are particularly severe.
The regulatory model of deterrence
The way we as a society deal with the fact that as recreational narcotics alcohol and tobacco are both pleasing to their consumers and unhealthy, harmful and dangerous at the same time, is that we regulate them. By this we mean that alcohol and tobacco can only be sold in certain forms (i.e. pure and with the strength known in advance), in certain places (bars / tobacconists), and with certain warnings attached so that consumers may be more inclined to make rational healthcare decisions about their own lives. As a society we also get to control supply and demand to an extent through the regulation of pricing: that is to say, through taxation.
The reason we do not ban alcohol and tobacco tomorrow is because the effect of those bans would be that we would lose all the abovementioned benefits of regulated sales but without reducing demand or consumption. People would just get alcohol or tobacco anyway, and it would not be quality controlled. In every society that has sought to ban alcohol it is still available, often made in dangerous ways and sold at extortionate prices: but available nonetheless. The hold of tobacco smoking over populations is so much stronger that we are not aware of any society that has sought to ban it outright.
Now we should consider the cross-substitutional effects of the use of recreational narcotics. Anecdotal evidence suggests:
People who drink alcohol are more likely to smoke more tobacco while doing so.
People taking MDMA are likely to drink less alcohol than they otherwise would.
People taking MDMA may feel inclined to smoke tobacco while the MDMA has effect.
Because MDMA is cheap (an Ecstasy tablet in Europe may have a street price of EUR 5 to 10), freer availability may cause cross- substitution from substantially more expensive and harmful narcotics such as cocaine (European street price EUR 80 per gramme) and heroin (European street price EUR 60 per gramme). This logic applies less in Latin America where cocaine prices are so exponentially cheaper. But any method by which demand in the context of the global cocaine pandemic (enormously wasteful of resources and undoubtedly dangerous for a lot of consumers up to and including mortality) can be reduced is at the least a collateral benefit.
The recreational narcotic with which MDMA is most commonly cross-substituted - amphetamine (also known as Wizz or crystal meth in its various forms) is much more harmful in that it is physically addictive and is shown to cause organ damage including skin tissue damage. Its effects are comparable but shorter term, making it more psychologically addictive as well. The reason it is cross+substituted is that it is even cheaper than MDMA. Surely the best way to combat amphetamine addiction is to bring its principal competitor in from the cold. In this way, regulated and with quality guaranteed, MDMA would become the recreational narcotic of choice over the various amphetamine variants. So we might hope and aim for.
There is no real evidence of a 'slippery slope' down the spectrum of recreational narcotics, as the recent global drive to legalise marijuana has shown. There is no grounded concern that smoking marijuana (itself a much more dangerous and unhealthy thing to do than taking MDMA) leads to the use of other recreational narcotics. There are no straightforward patterns but there is a lot of prejudice.
One interest group strongly against the legalisation of MDMA is the hospitality lobby. That is because they make their money in large part from selling alcoholic drinks; and a consumer of MDMA t(a substance that is very cheap in comparison with alcohol) typically drinks far less alcohol over the course of any period than were he or she not consuming MDMA. Hence the hospitality trade foresees a marked drop in profits associated with what they imagine to be higher levels of MDMA availability and consumption consequent upon its legalisation. Nevertheless maybe the alcoholic drinks sector could do with some pruning in the interests of a healthier society. Alcohol is a poison, a social harm in respect of which measures to disincentivise its voluntary use may be appropriate. In any event, we wouldn't know the effect of MDMA legalisation on the hospitality sector unless and until we tried it.
Now consider the following. MDMA can be manufactured by a reasonably competent chemist with a rough set of equipment from chemicals that are perfectly legal to purchase or obtain. Although MDMA is illegal to produce, supply or possess in the Netherlands, the vast majority of Europe's MDMA is manufactured there simply because the courts and police do not prioritise the pursuit and prosecution of what they see as victimless crime in respect of which Judges in any event are very unlikely to issue a custodial sentence because there is no violence involved. The net product of these Ecstasy factories in the Netherlands are bags of small, coloured pills that are notoriously easy to slip across borders without surveillance. Within the EU there are not supposed to be customs checks across borders. Hence the European prohibitionist against MDMA is fighting a losing battle. Ecstasy tablets are available in (virtually) every European capital where people want to buy them; and short of forcing the Netherlands to rewrite its criminal law and reprioritise its policing, there is absolutely nothing that anyone can do about the fact that as a general rule there is enough Ecstasy to satisfy demand all over Europe.
Hence the notion of suppressing demand or supply through criminalisation is a fantasy. With a Europe-wide criminalisation policy, which is what we have now, prices are rock bottom and supply meets demand. Hence nothing is lost by abandoning the policy of prohibition in favour of a more progressive regulatory regime. Indeed there is everything to gain, if we can establish quality control for the chemicals that our young people are voluntarily putting into their bodies. Our overriding priority is surely that those young people are safe, and that is why a change in the law from criminalisation to regulation is surely overdue. The steps towards abolition should be staged and each individually thought through, as they have been with csmahis legalisation, so that any putative step cam be reversedshould it be shown to have deleterious results. But in the end we may all end up wondering what the fuss was about.
The author wishes to thank the many dozens of young people who agreed to speak with him about this subject and whose anecodtal (and sometimes more than anecdotal) experiences and evidence contributed to this article's texture.
The author is also grateful to the time spent explaining the evidence for some scientists' belief in the neurotoxicity of MDMA by a skilled person.
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