Ecstasy (3, 4-methylenedioxymethamphetamine) use among Japanese rave population
Correspondence: Takuya Shimane, MPH, PhD, National Center of Neurology and Psychiatry, 4-1-1 Ogawa-Higashi, Kodaira, Tokyo 187-8553, Japan. Email: firstname.lastname@example.org
The aim of this study was to examine the prevalence of 3, 4-methylenedioxymethamphetamine (MDMA) use and to identify characteristics of MDMA users among rave attendees in Japan. This is the first rave-population study focusing on MDMA use in Japan.
The anonymous self-administrative questionnaire was conducted using laptop computers at four rave parties at three different venues in Tokyo, Japan. Participants were asked about lifetime use of MDMA and other club drug use, characteristics of rave attendance, and their demographics.
Questionnaires were completed by 300 rave attendees (47.3% female), 68.3% of whom were aged 20–29 years, and 92.3% of whom had completed high school. Among the participants, 8.0% reported MDMA use. Compared with ‘non-drug controls’ (the participants who had never used any illicit drugs), MDMA users were significantly more likely to be 30–39-year-old men. In addition, compared with ‘cannabis users’ (non-MDMA users who had used cannabis), MDMA users were significantly more likely to use other drugs and reported more adverse health effects due to ‘polydrug use’. Furthermore, MDMA users were significantly more likely to go to raves and preferred smaller venues.
Our results clearly suggest that rave attendees have a higher lifetime prevalence of MDMA use than the Japanese general population (0.2% reported in 2007). MDMA users are deeply involved in rave parties, and MDMA use may have high potential to generate close relationships among rave attendees. Therefore, MDMA users may have more opportunities to access MDMA than cannabis users and non-drug controls.
‘ECSTASY’ (3, 4-METHYLENEDIOXYMETHAMPHETAMINE [MDMA]) is a major club drug that has both stimulant and hallucinogenic properties. MDMA use has a variety of negative health effects, including tachycardia, trismus, bruxism, dry mouth, tremor, palpitations, diaphoresis, and parasthesias. Hyperthermia, a marked rise in body temperature, is the most severe adverse effect of MDMA.[2, 3] In addition, several studies have indicated that MDMA can be addictive.[4-6] Since the late 1980s, the recreational use of MDMA among young people has been connected to dance music (e.g., Acid House), and it is extensive in the rave scene.[7, 8] ‘Raves’ are all-night dance parties attended by a large number of youths who dance vigorously and continuously to repetitive electronic music played by celebrated disc jockeys. They are held in clandestine locations, including warehouses, nightclubs, and farm fields.
In Japan, MDMA use has emerged in the last decade, with several reported cases of MDMA intoxication. The first reported case in 2002 was a 23-year-old foreign woman who was found lying on the floor of a bathroom after taking an MDMA tablet. Also, a 28-year-old HIV-positive man who had sex with men was admitted to a hospital with muscle and knee-joint pain, convulsions, and loss of consciousness after taking MDMA, 5-MeO-DIPT, and amyl nitrite. In addition, fatal MDMA intoxication has been reported, and most cases were related to rave parties.[13-15] Furthermore, the number of MDMA-related arrests and seizures in Japan has drastically increased in the last decade. Although MDMA is a growing public health concern in Japanese society, no epidemiological studies have targeted MDMA use in Japan. Internationally, epidemiological studies of club drugs involved recruited subjects through snowball sampling, flyers and word of mouth, and school settings in the 1990s. In the 2000s, a number of investigations have been conducted at dance events or rave parties.[18-21] However, in the addiction field, no epidemiological studies have targeted the rave population in Japan. Thus, very little is known about the epidemiology of MDMA use among Japanese rave attendees.
The purpose of the present study was to examine the prevalence of MDMA use and to identify characteristics of MDMA users among rave attendees in Japan. In this study, we hypothesized that Japanese rave attendees have a higher lifetime prevalence of MDMA use than the Japanese general population. This is not only the first rave population study in the addiction field, but also the first epidemiological study focusing on MDMA use in Japan.
Participants were recruited between October 2010 and February 2011 at four rave parties at three different venues in Tokyo. All four parties were medium-scale (ranging from 150 to 600 attendees) and were held indoors at private venues. Three of the rave parties were reggae/dancehall music, and one was house music.
Trained field staff approached all visitors who entered the venues at the entrance and recruited participants, handing them cards that provided information about this survey. Visitors who received this card and brought it to the survey booth qualified as study participants. Responses to these cards were also utilized to calculate the participation rate and to exclude overlapping subjects.
The survey booth was secured at a relatively quiet spot away from the dance floor (e.g., a lounge area and an entrance area). The anonymous self-administered questionnaire was conducted using laptop computers in which the questionnaire had been installed with Adobe Flash Player (Adobe Systems, San Jose, CA, USA) and offline settings. The laptop computers were set on tables in the survey booth. When visitors voluntarily showed up at the survey booth, the field staff collected their cards and led them to the laptop computers. Informed consent was provided on the computer monitor at the beginning of the program.
Information requested by the survey questions included demographic data (sex, age, and education level), drug use, and characteristics of rave attendance. In this study, the drugs included were cannabis, MDMA, methamphetamine, ketamine, organic solvents, cocaine, and benzodiazepines. Those participants who had consumed any drug were asked about their drug-use patterns and drug-use-related experiences, including adverse health effects related to drug use. Participants were also asked about their rave attendance, including frequency of rave attendance in the past year, frequency of staying at raves all night in the past year, the type of rave party the participant most frequently attended, the size of the respondent's favorite venue, and the motivation for rave attendance (e.g., to ‘raise my energy level,’ ‘refresh my mind,’ or ‘step over the line’). Generally, it took 5–10 min for the participants to respond to the questionnaire.
After completing the questionnaire, all participants were given a drink ticket valued at 500 yen ($US6), which was valid at only that party. The participants were also given a card that provided the principal investigator's contact information and the website that would present the study findings. The present study protocols were approved by the National Center of Neurology and Psychiatry of Japan, Institutional Review Board.
At the four rave parties, 673 cards were handed out, and 324 attendees (participation rate of 48.1%) completed the questionnaire. As this survey was conducted at different rave parties at the same venue, the subjects could possibly overlap. To exclude overlapping subjects, participants were asked about the number of surveys they had completed. The 19 participants who reported that they had answered the survey more than once were excluded from the dataset.
Data from the remaining 305 participants were analyzed in the following steps. We first divided the participants into two groups according to MDMA use: one group consisted of the participants who had used MDMA (‘MDMA users’) (n = 24), and the other group included those who had never used MDMA (‘non-MDMA users’) (n = 281). The non-MDMA-user group included 74 cannabis users. We therefore subdivided the non-MDMA users into ‘cannabis users’ (n = 74) and ‘non-cannabis users’ (n = 207). However, the non-cannabis users included five participants who reported that they had used drugs other than MDMA and cannabis (there were two cases for organic solvents, two cases for other drugs, and one case for benzodiazepines.) To compare the two groups of drug users (MDMA users and cannabis users) with the participants who had never used any illicit drugs, we excluded these five participants from the group of non-cannabis users and classified the rest of the participants as ‘non-drug controls’ (n = 202). Finally, we included the remaining MDMA users (n = 24), non-MDMA users who had used cannabis (n = 74), and the participants who had never used any illicit drugs (n = 202) in data analysis.
Fisher's exact tests with Bonferroni correction (P < 0.025) were used to compare the three groups with respect to demographics and characteristics of rave attendance. Fisher's exact tests were used to compare the two groups of drug users (MDMA users and cannabis users) with respect to drug-use-related variables. Mann–Whitney U-tests were used to compare the two groups of drug users (MDMA users and cannabis users) with respect to the number of drugs they used. The threshold for statistical significance was set at P < 0.05 (two-tailed).
Table 1 shows the demographics of the three groups. Questionnaires were completed by 142 women and 156 men, with two participants not indicating their sex. The largest age group, 20–29 years, included 205 participants. Education levels were fairly high, with 92.3% having completed high school and 61.0% having completed post-secondary education (e.g., college or university). Compared with the non-drug controls, MDMA users were significantly more likely to be male and to be 30–39 years old. No statistical significance was found in education level.
Table 1. Demographics of the three groups
|Sex|| || || || ||0.846||0.007|
|Male||156 (52.0)||18 (75.0)||51 (68.9)||87 (43.1)|| || |
|Female||142 (47.3)||6 (25.0)||22 (29.7)||114 (56.4)|| || |
|Unknown||2 (0.7)||0 (0.0)||1 (1.4)||1 (0.5)|| || |
|Age group (years)|| || || || ||0.027||0.001|
|Under 19||10 (3.3)||0 (0.0)||1 (1.4)||9 (4.5)|| || |
|20–29||205 (68.3)||9 (37.5)||50 (67.6)||146 (72.3)|| || |
|30–39||76 (25.3)||14 (58.3)||21 (28.4)||41 (20.3)|| || |
|40 or older||9 (3.0)||1 (4.2)||2 (2.7)||6 (3.0)|| || |
|Education|| || || || ||0.203||0.272|
|Completed junior high school||23 (7.7)||4 (16.7)||4 (5.4)||15 (7.4)|| || |
|Completed high school||94 (31.3)||7 (29.2)||29 (39.2)||58 (28.7)|| || |
|Completed college or university||183 (61.0)||13 (54.2)||41 (55.4)||129 (63.9)|| || |
Table 2 shows the percentages of participants who had used various drugs among the two groups of drug users. Among the participants, 8.0% reported MDMA use. Among rave attendees, the most frequently indicated drugs were cannabis, followed by MDMA, methamphetamine, cocaine, organic solvents, ketamine, and benzodiazepines. MDMA users were significantly more likely than cannabis users to use all other drugs: cocaine, methamphetamine, ketamine, organic solvents and benzodiazepines. In addition, MDMA users reported having used a significantly larger number of drugs than cannabis users.
Table 2. Percentages of participants who had used various drugs among the two groups of drug users
|Drugs used|| || || || |
|Cannabis||98 (32.7)||24 (100.0)||74 (100.0)||–|
|Cocaine||19 (6.3)||15 (62.5)||4 (5.4)||<0.001|
|Methamphetamine||19 (6.3)||14 (58.3)||5 (6.8)||<0.001|
|Organic solvents||12 (4.0)||7 (29.2)||5 (6.8)||0.008|
|Ketamine||10 (3.3)||8 (33.3)||2 (2.7)||<0.001|
|Benzodiazepines||8 (2.7)||7 (29.2)||1 (1.4)||<0.001|
|Other||9 (3.0)||6 (25.0)||3 (4.1)||0.006|
|Mean number of drugs used||0.68||4.54||1.27||<0.001**|
Table 3 shows the percentages of particular drug-use patterns and drug-use-related experiences among the two groups of drug users. Among the two groups of drug users (MDMA users and cannabis users), about 70% reported using drugs outside of rave settings, and about 10% reported using drugs at rave parties in the past. No significant difference was observed between the drug use patterns of MDMA users and cannabis users. MDMA users were significantly more likely to have drug-related episodes than cannabis users, including ‘get[ting] into the music’, ‘enhanced enjoyment’, ‘feel[ing] euphoric’, ‘enhanced sexual pleasure’, and ‘hallucination’. In addition, MDMA users reported significantly more adverse health effects due to ‘overdose’ and ‘polydrug use’. However, no statistical significance was found for adverse health effects due to mixing with alcohol and panic attacks.
Table 3. Percentage of drug-use patterns and drug-use-related experiences among the two groups of drug users
|Drug-use patterns|| || ||0.875|
|Use before rave parties||5 (20.8)||14 (17.7)|| |
|Use at rave parties||3 (12.5)||8 (10.1)|| |
|Use in out-of-rave settings||16 (66.7)||52 (70.3)|| |
|Drug-use-related experiences (lifetime)|| || || |
|Get into the music||18 (75.0)||34 (45.9)||0.018|
|Enhanced enjoyment||17 (70.8)||33 (44.6)||0.034|
|Feel euphoric||15 (62.5)||23 (31.1)||0.008|
|Enhanced sexual pleasure||15 (62.5)||19 (25.7)||0.002|
|Hallucinations||12 (50.0)||7 (9.5)||<0.001|
|Adverse health effects due to overdose||12 (50.0)||13 (17.6)||0.003|
|Adverse health effects due to polydrug use||4 (16.7)||2 (2.7)||0.030|
|Adverse health effects due to simultaneous consumption of alcohol||6 (25.0)||10 (13.5)||0.210|
|Panic attacks||3 (12.5)||4 (5.4)||0.357|
Table 4 shows the characteristics of rave attendance among the three groups. Among the participants, MDMA users were significantly more likely to go to a rave than non-drug controls, and more MDMA users preferred smaller venues than cannabis users, and non-drug controls. However, no significant difference in frequency of staying overnight and preferred type of rave party was observed between the three groups. MDMA users were significantly more likely to go to rave parties for such motivation as stepping over the line and feeling at home than non-drug controls were.
Table 4. Characteristics of rave attendance among the three groups
|Frequency of rave attendance in the past year|| || || || ||0.405||0.010|
|More than twice per week||41 (13.7)||9 (37.5)||12 (16.2)||20 (9.9)|| || |
|Once per week||55 (18.3)||3 (12.5)||16 (21.6)||36 (17.8)|| || |
|Once per month||83 (27.7)||7 (29.2)||27 (36.5)||49 (24.3)|| || |
|Twice per year||63 (21.0)||4 (16.7)||12 (16.2)||47 (23.3)|| || |
|Once per year||19 (6.3)||0 (0.0)||2 (2.7)||17 (8.4)|| || |
|Less than once per year||39 (13.0)||1 (4.2)||5 (6.8)||33 (16.3)|| || |
|Frequency of staying at raves all night in the past year|| || || || ||0.303||0.051|
|Always||86 (28.7)||8 (33.3)||24 (32.4)||54 (26.7)|| || |
|Usually||75 (25.0)||7 (29.2)||18 (24.3)||50 (24.8)|| || |
|Often||41 (13.7)||7 (29.2)||11 (14.9)||23 (11.4)|| || |
|Sometimes||38 (12.7)||1 (4.2)||12 (16.2)||25 (12.4)|| || |
|Rarely||33 (11.0)||0 (0.0)||6 (8.1)||27 (13.4)|| || |
|Never||27 (9.0)||1 (4.2)||3 (4.1)||23 (11.4)|| || |
|Most-frequented type of rave party|| || || || ||0.426||0.641|
|Reggae||180 (60.0)||13 (54.2)||46 (62.2)||121 (59.9)|| || |
|Hip hop||68 (22.7)||6 (25.0)||16 (21.6)||46 (22.8)|| || |
|Techno||6 (2.0)||1 (4.2)||1 (1.4)||4 (2.0)|| || |
|House||13 (4.3)||0 (0.0)||5 (6.8)||8 (4.0)|| || |
|Trance||2 (0.7)||0 (0.0)||1 (1.4)||1 (0.5)|| || |
|Electro||7 (2.3)||1 (4.2)||2 (2.7)||4 (2.0)|| || |
|Size of favorite venue|| || || || ||0.002||0.005|
|More than 1000 people||20 (6.7)||1 (4.2)||3 (4.1)||16 (7.9)|| || |
|500–1000 people||37 (12.3)||0 (0.0)||10 (13.5)||27 (13.4)|| || |
|300–500 people||63 (21.0)||10 (41.7)||12 (16.2)||41 (20.3)|| || |
|100–300 people||106 (35.3)||12 (50.0)||26 (35.1)||68 (33.7)|| || |
|Fewer than 100 people||74 (24.7)||1 (4.2)||23 (31.1)||50 (24.8)|| || |
|Motivation for rave attendance|| || || || || || |
|Raise my energy level||195 (65.0)||20 (83.3)||48 (64.9)||127 (62.9)||0.126||0.068|
|Refresh my mind||149 (49.7)||15 (62.5)||38 (51.4)||96 (47.5)||0.359||0.198|
|Step over the line||71 (23.7)||12 (50.0)||18 (24.3)||41 (20.3)||0.023||0.004|
|Enjoy an extraordinary atmosphere||82 (27.3)||10 (41.7)||27 (36.5)||45 (22.3)||0.809||0.045|
|Feel safe||39 (13.0)||6 (25.0)||13 (17.6)||20 (9.9)||0.553||0.041|
|Feel at home||45 (15.0)||9 (37.5)||15 (20.3)||21 (10.4)||0.105||0.001|
|Change myself||31 (10.3)||5 (20.8)||11 (14.9)||15 (7.4)||0.530||0.045|
Compared to drug use prevalence indicated in representative general population surveys in Japan, our results clearly suggest that rave attendees have a higher lifetime prevalence of drug use than the general population. The results of a 2007 nationwide general population survey on drug use indicated that solvent inhalants are the most frequently used drugs (lifetime prevalence of 2.0%), followed by cannabis (0.8%) and methamphetamine (0.4%). MDMA use was lower than other substance use, with a lifetime prevalence of only 0.2% among the general population. In addition, regarding lifetime prevalence of drug use among the general population, the World Mental Health Survey Japan 2002–2004 listed cannabis (1.5%) and cocaine (0.3%) as the most prevalent. However, our results indicated that the lifetime prevalence of drug use was 15–40 times higher among rave attendees than among the general population.
In Japan, a zero-tolerance policy towards illicit drugs has been the traditional approach, and the use and possession of such drugs as methamphetamine and MDMA have been strictly prohibited by law. Thus, it is assumed that drug use is underreported due to drug users' tendency to keep their drug use a secret; however, compared to general population surveys in the USA, Japan has clearly exhibited a low lifetime prevalence of drug use.[25, 26] The same trends are indicated among the rave population. Canadian youth who attended raves reported higher lifetime prevalence than Japanese rave attendees among our subjects: cannabis (91.4% vs 32.7%), methamphetamine (73.3% vs 6.3%), and MDMA (65.2% vs 8.0%). Therefore, the low prevalence of drug use among the Japanese general population may cause the low prevalence among rave populations.
MDMA use in the rave setting is often combined with the use of alcohol or other drugs, such as cannabis, mushrooms, and various prescription drugs.[18, 19] Among Canadian rave attendees, the drug most frequently used with MDMA was cannabis (68.5%), followed by amphetamines (48.4%) and/or alcohol (45.2%) at the most recent rave event attended. In terms of poly-club-drug combinations, MDMA was most often cited in combination with other club drugs among rave-going young adults in New York City.
The present study indicates that MDMA users have a higher prevalence of cannabis, cocaine, and methamphetamine. Furthermore, MDMA users were using a larger variety of drugs than cannabis users, and 25% of the MDMA users reported adverse health effects due to mixture with alcohol. Although this finding seems consistent with that of previous studies, our study investigated lifetime experience of drug use, rather than current use or drug use in rave settings. However, the proportion of MDMA users who had experienced adverse health effects due to polydrug use was significantly higher than that of cannabis users. This finding may indicate the potential risk for polydrug use among MDMA users. Further investigation should focus on polydrug use in rave settings in Japan.
We also found a significant association between characteristics of rave attendance and MDMA use. Compared to non-drug controls, MDMA users were likely to attend rave parties more frequently, and prefer smaller venues. Such deep involvement in rave parties may have high potential to generate close relationships among rave attendees. Although the availability of club drugs in Japanese rave settings is unknown, the availability of MDMA in Japanese rave settings is thought to be higher than in other settings. Therefore, MDMA users may have more opportunities to access MDMA than non-drug controls do. A positive correlation between the rave attendance and substance use was reported in Canada. Our results may indicate a similar trend.
The present study should be understood on the premise of the following limitations. First, our results may not be representative of the rave population in Japan because our subjects were not recruited through random sampling but through convenience sampling at specific venues in Tokyo. Recent rave population studies on club drugs recruited subjects through time–space sampling that was intended to generalize club drug use among this population. Since the social stigma associated with drug use is extremely high in Japan, it was difficult to obtain the consensus of venues to conduct this survey. For example, several venues refused to be survey sites because they did not want us to ask their visitors about drug use. Therefore, random selection of venues with time–space sampling was not feasible for us, and we adopted convenience sampling at specific venues. In addition, selection bias for rave attendees was possible because the type of party at which the survey was conducted was biased toward reggae music. Some research indicates a significant relationship between club drug use and the preferred type of party/music.[17, 21]
Second, it is possible that our finding on drug use prevalence may not be accurate because our study relied exclusively on drug users' self-reporting in a party atmosphere. Typically, rave events produce an extraordinary atmosphere with light and sound, and most of the attendees drink alcohol. Conducting a survey in such a setting could result in unreliable data. However, a study of MDMA use at rave parties in the Netherlands indicated that people high on MDMA in a party atmosphere can be reliably assessed. In addition, several studies have indicated that substance use self-reports are generally valid and reliable.[27, 28]
Despite these limitations, this is the first rave population study in the addiction field in Japan, and our findings suggest the importance of club drug prevention for the Japanese rave population.
The present study was not only the first Japanese rave population survey of club drugs, but also the first epidemiological study focusing on MDMA use in Japan. Our results clearly suggest that rave attendees have a higher lifetime prevalence of MDMA use than the general population. MDMA users were likely to attend rave parties more frequently and to prefer smaller venues. Deep involvement with rave parties may have a high potential to generate close relationships among rave attendees. Therefore, MDMA users may have more opportunities to access MDMA than non-drug controls do.
This work was supported by Health and Labour Sciences Research Grants for Research on Regulatory Science of Pharmaceuticals and Medical Devices from the Ministry of Health, Labour and Welfare of Japan. All authors declare that they have no conflicts of interest. Drs Shimane and Hidaka designed the study. Dr Shimane conducted the analysis and wrote the first draft. Drs Wada and Funada contributed to the interpretation and critical revisions of the paper. All authors contributed to and approved the final manuscript.